Nursing Elites

1. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

• A. Hepatitis B
• B. Polio
• C. Measles, mumps, and rubella (MMR)
• D. Hemophilus influenzae type B (Hib)

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

2. What is the most important intervention in the management of a child with sickle cell crisis?

• A. Administration of iron supplements
• B. Initiation of high-calorie diet
• C. Administration of pain relief
• D. Limiting fluid intake

Correct answer: C

Rationale: The most important intervention in managing a child with sickle cell crisis is the administration of pain relief. During a sickle cell crisis, severe pain is a prominent symptom due to vaso-occlusive episodes. Effective pain management, along with adequate hydration and oxygen therapy, is crucial in treating a sickle cell crisis and preventing further complications. Choice A, the administration of iron supplements, is not the priority during a sickle cell crisis. Iron supplements are typically used to manage anemia in individuals with sickle cell disease but are not the primary intervention during a crisis. Choice B, the initiation of a high-calorie diet, is not the most critical intervention during a sickle cell crisis. While proper nutrition is important in managing sickle cell disease, it is not the immediate priority during a crisis. Choice D, limiting fluid intake, is not recommended during a sickle cell crisis. Hydration is essential in managing sickle cell crisis to prevent complications like dehydration and further vaso-occlusive episodes.

3. A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?

• A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
• B. Risk for aspiration related to feeding the infant an inappropriate food
• C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
• D. Readiness for enhanced nutrition, related to the age of the infant

Correct answer: B

Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.

4. What measure of fluid balance status is most useful in a child with acute glomerulonephritis?

• A. Proteinuria
• B. Daily weight
• C. Specific gravity
• D. Intake and output

Correct answer: B

Rationale: Daily weight is the most accurate measure of fluid balance in children with acute glomerulonephritis, as it reflects changes in body fluid status more reliably than other measures like proteinuria or specific gravity.

5. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?

• A. Keep baby powder out of reach.
• B. Inspect toys for removable parts.
• C. Allow the infant to take a bottle to bed.
• D. Teething biscuits can be used for teething discomfort.

Correct answer: A

Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.

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