Nokea
The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?
- A. I will use precautions when I give an infant oral care
- B. I will use precautions when I change an infant's diaper
- C. I will use precautions when I come in contact with blood and body fluids
- D. I will use precautions when administering oral medications to a school-age child
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An infant has been diagnosed with failure to thrive (FTT) classified according to the pathophysiology of defective utilization. The nurse understands that the reason for the FTT is most likely related to what?
- A. Cystic fibrosis
- B. Hyperthyroidism
- C. Congenital infection
- D. Breastfeeding problems
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What time frame has the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommended that pregnant adolescents and women who are not protected against pertussis receive the tetanus, diphtheria, and pertussis (Tdap) vaccine?
- A. Between 27 and 36 weeks of gestation or postpartum before discharge from the hospital
- B. During the first prenatal visit when pregnancy is confirmed
- C. The vaccine should be administered 24 hours prior to delivery
- D. This vaccine is only recommended during the first trimester
Correct Answer: A
Rationale: The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommend that pregnant adolescents and women without protection against pertussis should receive the Tdap vaccine ideally between 27 and 36 weeks of gestation or postpartum before discharge from the hospital. This timeframe allows for the development of antibodies in the mother to protect her and provide passive immunity to the infant. Administering the vaccine during the first trimester (Choice D) is not recommended as the optimal time is between 27 and 36 weeks. Choice B, during the first prenatal visit, is too early for optimal protection, and Choice C, 24 hours prior to delivery, does not provide enough time for the vaccine to be effective before birth.
An intravenous line is needed in a school-age child. What medication is an appropriate analgesic for use with this patient?
- A. TAC (tetracaine, epinephrine [Adrenalin], cocaine) 15 minutes before the procedure.
- B. A transdermal fentanyl (Duragesic) patch at the site of venipuncture.
- C. EMLA (eutectic mixture of local anesthetics) immediately before the procedure.
- D. LMX (4% liposomal lidocaine cream) 30 minutes before the procedure.
Correct Answer: D
Rationale: LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin, making it more suitable for wound suturing. Transdermal fentanyl patches are designed for continuous pain control, not rapid pain control needed for a procedure like venipuncture. EMLA, for maximum effectiveness, must be applied approximately 60 minutes before the procedure, making it less suitable for immediate pain relief required for intravenous line placement.
A nurse is working with the local community on promoting physical fitness for children. The nurse encourages the community to develop programs that meet the needs of the school-aged child for physical activity, based on the understanding that this age group requires how much physical activity daily?
- A. 30 minutes
- B. 60 minutes
- C. 90 minutes
- D. 15 minutes
Correct Answer: B
Rationale: The correct answer is B: 60 minutes. School-aged children require at least 60 minutes of physical activity daily according to recommendations. This level of activity helps in promoting overall health, development, and well-being. Choice A (30 minutes) is incorrect as it falls short of the recommended duration. Choice C (90 minutes) is excessive and not the standard guideline for this age group. Choice D (15 minutes) is insufficient to meet the physical activity needs of school-aged children.
What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
- A. Playing peek-a-boo
- B. Playing pat-a-cake
- C. Imitating animal sounds
- D. Showing how to clap hands
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.