Nursing Elites

1. The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?

• A. Use of protective barriers during sexual activity prevents most strains of HPV infection
• B. Most adolescents are not honest about being sexually active
• C. Not all strains of HPV will be covered if given at a later date
• D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer

Correct answer: D

Rationale: Administering the HPV vaccine helps establish immunity before potential exposure to the virus, reducing the risk of HPV infection and subsequent development of cervical cancer. It is recommended to vaccinate adolescents before they become sexually active for maximum effectiveness. Choice A is incorrect because while protective barriers can reduce the risk, they do not prevent all strains of HPV. Choice B is incorrect and judgmental as it assumes dishonesty without providing relevant information about HPV vaccination. Choice C is incorrect as it downplays the importance of vaccination by suggesting that not all strains are necessary to cover, which is not the case in preventing HPV-related diseases.

2. The nurse is assessing a 4-month-old infant who has just received routine immunizations. The mother reports that the baby has been fussy and has a low-grade fever since the immunizations. What is the best response by the nurse?

• A. These are common side effects and should resolve within a few days
• B. Your baby may be having an allergic reaction to the immunizations
• C. You should bring your baby to the clinic immediately for evaluation
• D. You should give your baby aspirin to help with the fever

Correct answer: A

Rationale: The correct response by the nurse is to reassure the mother that fussiness and low-grade fever are common side effects of immunizations in infants and should resolve within a few days. It is essential to educate the mother about these expected reactions to alleviate her concerns. Choice B is incorrect because allergic reactions to immunizations usually present with more severe symptoms such as difficulty breathing or swelling. Choice C is not warranted unless there are concerning symptoms present. Choice D is inappropriate as aspirin is contraindicated in infants due to the risk of Reye's syndrome.

3. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?

• A. Administer a diuretic as prescribed
• B. Restrict the child’s fluid intake
• C. Notify the healthcare provider
• D. Measure the child’s abdominal girth

Correct answer: C

Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.

4. A child with sickle cell anemia is being treated for a vaso-occlusive crisis. Which intervention should the practical nurse (PN) implement?

• A. Apply cold packs to painful areas.
• B. Encourage increased fluid intake.
• C. Administer high doses of vitamin C.
• D. Provide low-calorie meals.

Correct answer: B

Rationale: Encouraging increased fluid intake is crucial in managing vaso-occlusive crises in patients with sickle cell anemia. Dehydration can worsen these crises, so adequate hydration is essential to prevent complications and improve outcomes. Applying cold packs to painful areas may exacerbate vaso-occlusive crises by causing vasoconstriction. Administering high doses of vitamin C is not directly indicated for vaso-occlusive crises in sickle cell anemia. Providing low-calorie meals is not the priority during a vaso-occlusive crisis; maintaining adequate nutrition is important, but hydration takes precedence in this situation.

5. A parent of a 2-month-old infant, who was treated for pyloric stenosis, is receiving discharge instructions from a healthcare provider. Which statement by the parent indicates a need for further teaching?

• A. We will burp our baby more frequently during feedings
• B. We should feed our baby in an upright position
• C. We will lay our baby on their stomach after feeding
• D. We will start feeding our baby with small, frequent feedings

Correct answer: C

Rationale: Placing infants on their stomach after feeding increases the risk of sudden infant death syndrome (SIDS). It is important to educate parents to always place infants on their back to sleep to reduce this risk.

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