Nursing Elites

1. When discussing the side effects of the Haemophilus influenzae (Hib) vaccine with parents, which sign should the nurse mention for an infant receiving the vaccine?

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

Correct answer: D

Rationale: The correct answer is 'Low-grade fever.' A low-grade fever is a typical, mild side effect that can occur after the Hib vaccine is administered. It is a sign that the body's immune system is responding to the vaccine and is generally not a cause for concern. Lethargy, urticaria, and generalized rash are not commonly associated side effects of the Hib vaccine. Lethargy may be a sign of other issues, while urticaria and generalized rash are more indicative of allergic reactions rather than typical responses to the Hib vaccine.

2. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

• A. distal capillary refill
• B. systolic blood pressure
• C. skin color and temperature
• D. presence of peripheral pulses

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

3. A 3-year-old child with a history of frequent respiratory infections is being evaluated for cystic fibrosis. What diagnostic test should the nurse anticipate will be ordered?

• A. Chest X-ray
• B. Sweat chloride test
• C. Pulmonary function test
• D. Sputum culture

Correct answer: B

Rationale: The correct answer is the sweat chloride test. This test is crucial in diagnosing cystic fibrosis as it measures the amount of chloride in sweat, which is typically elevated in individuals with cystic fibrosis. A chest X-ray (Choice A) may show characteristic findings like hyperinflation or bronchiectasis, but it is not a definitive diagnostic test for cystic fibrosis. Pulmonary function tests (Choice C) may help assess lung function but are not specific for cystic fibrosis. Sputum culture (Choice D) may be used to identify specific pathogens causing respiratory infections but is not a primary diagnostic test for cystic fibrosis.

4. Where should the child admitted with injuries that may be related to abuse be placed?

• A. In a private room
• B. With an older, friendly child
• C. With a child of the same age
• D. In a room near the nurses’ desk

Correct answer: D

Rationale: The correct answer is to place the child in a room near the nurses’ desk. This placement allows for close monitoring and immediate intervention if needed, ensuring the safety and well-being of the child. Placing the child in a private room (Choice A) may limit visibility and monitoring. Putting the child with an older, friendly child (Choice B) or a child of the same age (Choice C) does not prioritize the necessary close monitoring and intervention that a child potentially experiencing abuse requires. Hence, placing the child in a room near the nurses’ desk is the most appropriate choice in this scenario.

5. What should the nurse advise the parents of a child with asthma on preventing asthma attacks?

• A. Avoid exposure to allergens
• B. Encourage regular exercise
• C. Provide a high-protein diet
• D. Increase fluid intake

Correct answer: A

Rationale: The correct answer is to advise the parents to avoid exposure to allergens. Asthma attacks are commonly triggered by allergens such as pollen, dust mites, pet dander, and mold. By minimizing the child's contact with these triggers, the likelihood of asthma attacks can be reduced. Encouraging regular exercise can be beneficial for overall health but may not directly prevent asthma attacks. Providing a high-protein diet and increasing fluid intake are important for general health but are not specific preventive measures for asthma attacks.

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