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A child receives a vaccine for MMR. Six hours after the injection, the child’s parent reports local soreness, erythema, lethargy, and a fever of 101°F to a nurse. Which action should the nurse take?
- A. Give instructions on relieving symptoms with acetaminophen
- B. Seek emergency help, because these symptoms are signs of anaphylactic reaction
- C. Tell the parent that a live vaccine will cause a mild case of measles
- D. Obtain and fill out a Vaccine Adverse Event Report form
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded from the plan of care?
- A. Immediate initiation of oral feedings
- B. Assessment of the surgical site
- C. Administration of opioid narcotics for pain management
- D. Visitation at the bedside
Correct Answer: A
Rationale: Immediate initiation of oral feedings is contraindicated post-abdominal surgery due to the risk of bowel complications such as paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase the risk of these complications and hinder the healing process. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site, administration of opioid narcotics for pain management, and visitation at the bedside are essential components of postoperative care and should not be excluded.
What is the most appropriate nursing consideration for a patient who is prescribed verapamil and digoxin?
- A. Restrict intake of oral fluids and high-fiber foods
- B. Take an apical pulse for 30 seconds before administration
- C. Notify the healthcare provider of nausea, vomiting, and visual changes
- D. Hold the medications if the heart rate is greater than 110 bpm
Correct Answer: C
Rationale: When a patient is prescribed verapamil and digoxin, it is crucial to monitor for signs of digoxin toxicity due to the potential interaction between these medications. Verapamil can elevate digoxin blood serum levels, increasing the risk of toxicity. Symptoms of digoxin toxicity include nausea, vomiting, and visual changes. Restricting intake of oral fluids and high-fiber foods is not a specific consideration related to this medication combination. Before administering digoxin, it is essential to take an apical pulse for a full minute, not just 30 seconds. Additionally, holding the medications if the heart rate exceeds 110 bpm is not a typical response to the combination of verapamil and digoxin, which can cause bradycardia rather than tachycardia.
Undescended testis is a risk factor for the development of which of the following tumors?
- A. rhabdomyosarcoma
- B. leukemia
- C. yolk sac tumor
- D. lymphoma
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You are evaluating a 9-year-old boy child with ALL who recently develops relapse; an important statement that should be mentioned to his parents is
- A. testicular relapse occurs in the majority of boys with ALL
- B. such relapse occurs as painful swelling of one or both testes
- C. the diagnosis is confirmed by ultrasonography
- D. the majority of affected boys can be successfully retreated, and the survival rate is good
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
At a 6-month well-child checkup, a male infant is weighed. The mother asks if his weight is normal. The nurse's best response is:
- A. At 6 months, his weight should be approximately three times his birth weight.
- B. Each child grows at their own pace.
- C. At 6 months, his weight should be approximately twice his birth weight.
- D. At 6 months, a child should weigh about 10 lb more than at birth.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.