Nursing Elites

1. A healthcare provider is educating a parent group about the importance of immunizations. Which disease can be prevented by the varicella vaccine?

• A. Measles
• B. Mumps
• C. Rubella
• D. Chickenpox

Correct answer: D

Rationale: The varicella vaccine is specifically designed to prevent chickenpox. Measles, mumps, and rubella are prevented by different vaccines: Measles is prevented by the measles, mumps, and rubella (MMR) vaccine; Mumps is prevented by the MMR vaccine; and Rubella is also prevented by the MMR vaccine. Therefore, the correct answer is D, Chickenpox, as it is the disease prevented by the varicella vaccine.

2. The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. What is the priority nursing diagnosis?

• A. Deficient fluid volume related to dehydration
• B. Excess fluid volume related to edema
• C. Deficient knowledge related to fluid intake regimen
• D. Imbalanced nutrition related to excess weight

Correct answer: A

Rationale: The priority nursing diagnosis for a 7-year-old boy with diabetes insipidus is deficient fluid volume related to dehydration. Diabetes insipidus causes excessive thirst and urination, leading to fluid imbalance and potential dehydration. Choice B, excess fluid volume related to edema, is not a priority as diabetes insipidus is characterized by fluid loss, not retention. Choice C, deficient knowledge related to fluid intake regimen, may be important but is not the priority when the child is at risk of dehydration. Choice D, imbalanced nutrition related to excess weight, is not directly associated with the primary concern of fluid volume imbalance in diabetes insipidus.

3. What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?

• A. Explaining the procedure in detail
• B. Encouraging deep breathing exercises
• C. Discussing the importance of hydration
• D. Using play therapy to prepare the child

Correct answer: B

Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.

4. After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?

• A. Preventing shivering
• B. Restricting oral fluids
• C. Measuring output hourly
• D. Taking vital signs hourly

Correct answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.

5. Following corrective surgery for hypertrophic pyloric stenosis (HPS), an infant is returned to the pediatric unit with an IV infusion in place. What is the priority nursing action?

• A. Apply adequate restraints.
• B. Administer a mild sedative.
• C. Assess the IV site for infiltration.
• D. Attach the nasogastric tube to wall suction.

Correct answer: C

Rationale: The priority nursing action after a corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial to ensure proper fluid administration and prevent complications such as extravasation or infiltration. Applying restraints (Choice A) is not indicated in this scenario and can compromise the infant's comfort and safety. Administering a mild sedative (Choice B) is not necessary and should only be done based on specific clinical indications. Attaching the nasogastric tube to wall suction (Choice D) may be important for certain conditions but is not the priority immediately post-surgery; assessing the IV site is more urgent to prevent potential complications related to IV therapy.

Similar Questions