Nursing Elites

1. What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?

• A. Place the infant in a warm, dry environment.
• B. Allow parents and siblings to visit.
• C. Maintain standard and contact precautions.
• D. Administer prescribed antibiotics immediately.

Correct answer: C

Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.

2. What should the nurse recommend to reduce the risk of sudden infant death syndrome (SIDS) in a 6-month-old infant?

• A. Place the infant on their back to sleep
• B. Use a pacifier during sleep
• C. Have the infant sleep on their side
• D. Keep the infant's room cool

Correct answer: A

Rationale: Placing the infant on their back to sleep is the correct recommendation to reduce the risk of sudden infant death syndrome (SIDS). This sleep position has been shown to significantly decrease the incidence of SIDS. Using a pacifier during sleep (Choice B) can also help reduce the risk, but it is secondary to the back sleeping position. Having the infant sleep on their side (Choice C) is not recommended, as it increases the risk of SIDS. Keeping the infant's room cool (Choice D) may provide a comfortable sleeping environment but does not directly reduce the risk of SIDS.

3. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect to find when palpating the infant’s abdomen?

• A. A distended colon
• B. Marked tenderness around the umbilicus
• C. An olive-sized mass in the right upper quadrant
• D. Rhythmic peristaltic waves in the lower abdomen

Correct answer: C

Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS, where the hypertrophied pyloric muscle forms a palpable mass in the abdomen. Choices A, B, and D are incorrect. A distended colon is not a typical finding in HPS, marked tenderness around the umbilicus is not specific to this condition, and rhythmic peristaltic waves in the lower abdomen are not associated with HPS.

4. A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching?

• A. We should give this drug after he eats something.
• B. We need to watch carefully for possible infections.
• C. The drug should not be stopped abruptly.
• D. He might experience weight gain with this drug.

Correct answer: A

Rationale: Giving prednisone with food helps prevent gastrointestinal upset. Therefore, the correct statement is that the drug should be given after the child eats something, not before. Watching for infections is important due to prednisone's immunosuppressive effects, making choice B correct. Choice C is accurate because prednisone should be tapered off gradually to prevent withdrawal symptoms. Weight gain is a common side effect of prednisone, so choice D is also correct. The incorrect statement is choice A, as prednisone should be administered after a meal.

5. The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?

• A. Lethargy
• B. Urticaria
• C. Generalized rash
• D. Low-grade fever

Correct answer: D

Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.

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