Nursing Elites

1. A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant’s discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?

• A. It should not be given until the infant reaches 2 years of age.
• B. Infants who are receiving chemotherapy should not be given these vaccines.
• C. It should be given to protect the infant from contracting any of these diseases.
• D. The parents should discuss this with their healthcare provider at the next visit.

Correct answer: B

Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.

2. A child with a diagnosis of hemophilia is admitted to the hospital with a bleeding episode. What is the priority nursing intervention?

• A. Administering pain medication
• B. Monitoring for signs of infection
• C. Administering factor VIII
• D. Ensuring a safe environment

Correct answer: C

Rationale: The priority nursing intervention for a child with hemophilia experiencing a bleeding episode is administering factor VIII. Hemophilia is a genetic disorder characterized by a deficiency in clotting factors, such as factor VIII. Administering factor VIII replacement therapy is crucial to stop or control bleeding in individuals with hemophilia. Options A, B, and D are important aspects of patient care but do not take precedence over addressing the underlying cause of the bleeding in a child with hemophilia, which is the deficiency of factor VIII.

3. When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?

• A. Administration of colloid initially followed by a crystalloid
• B. Determination of fluid replacement based on the type of burn
• C. Administration of most of the volume during the first 8 hours
• D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr

Correct answer: C

Rationale: The correct answer is C. In fluid replacement therapy for burns, the majority of the volume should be administered within the first 8 hours to prevent shock and maintain perfusion. Choice A is incorrect because crystalloids are typically administered first in fluid resuscitation for burns. Choice B is incorrect as fluid replacement in burn patients is primarily determined by the extent of the burn injury rather than the type of burn. Choice D is incorrect as the goal for hourly urine output in burn patients is generally higher, aiming for 1-2 mL/kg/hr in children to ensure adequate renal perfusion and prevent dehydration.

4. The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?

• A. abdominal rigidity and pain on palpation
• B. rounded abdomen and hypoactive bowel sounds
• C. visible peristalsis and weight loss
• D. distention of the lower abdomen and constipation

Correct answer: C

Rationale: Visible peristalsis and weight loss are classic clinical manifestations of pyloric stenosis. The obstruction at the pyloric sphincter causes visible peristalsis as the stomach tries to push food through the narrowed opening, leading to the appearance of waves across the abdomen. Weight loss occurs due to poor feeding and frequent vomiting associated with pyloric stenosis. Choices A, B, and D are incorrect. Abdominal rigidity and pain on palpation, rounded abdomen and hypoactive bowel sounds, as well as distention of the lower abdomen and constipation are not typically seen in pyloric stenosis.

5. The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching?

• A. We should avoid aspirin and drugs like ibuprofen.
• B. He should avoid participating in football for safety.
• C. Swimming would be a great activity.
• D. Our son cannot take any antihistamines.

Correct answer: B

Rationale: The correct answer is B. Participation in contact sports like football should be avoided in children with idiopathic thrombocytopenia due to the increased risk of bleeding. Choices A, C, and D are incorrect because avoiding aspirin and drugs like ibuprofen, engaging in activities like swimming, and avoiding antihistamines are all appropriate recommendations for a child with idiopathic thrombocytopenia to prevent bleeding episodes and ensure safety.

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