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A 3-year-old child is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the child has a fever and is breathing rapidly. What is the nurse's priority action?
- A. Administer antipyretic medication
- B. Obtain a chest X-ray
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In a child with pneumonia who is breathing rapidly, the priority action for the nurse is to start the child on oxygen therapy. This intervention is essential to ensure adequate oxygenation, which is crucial in managing respiratory distress and preventing complications associated with hypoxia. Administering antipyretic medication (Choice A) may help reduce the fever but does not address the immediate need for oxygen therapy. Obtaining a chest X-ray (Choice B) is important for diagnosis but providing oxygen is more urgent. Notifying the healthcare provider (Choice D) can be done after initiating oxygen therapy to update on the patient's condition.
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A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?
- A. Obtain vital signs to monitor for fluid overload
- B. Change IV site dressing every 3 days and as needed
- C. Monitor for signs of facial swelling or urticaria
- D. Assess for abdominal pain and vomiting
Correct Answer: C
Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.
The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first?
- A. Girls between ages 10 and 14.
- B. Boys between ages 10 and 14.
- C. Boys and girls between 12 and 14.
- D. Boys and girls between 8 and 12.
Correct Answer: A
Rationale: Corrected Question: The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first? Girls between ages 10 and 14 are at the highest risk for scoliosis and should be screened first as they have a higher incidence of developing scoliosis during their adolescent growth spurt. Early detection and intervention can help prevent further complications associated with scoliosis. Boys between ages 10 and 14 (choice B) are not at the highest risk compared to girls in the same age group. Boys and girls between 12 and 14 (choice C) are at a lower risk compared to girls between ages 10 and 14. Boys and girls between 8 and 12 (choice D) are at a lower risk group compared to girls between ages 10 and 14.
A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill of 2 seconds. Which information should the nurse discuss with the mother?
- A. Encourage the infant to play
- B. Limit the amount of oral intake
- C. Keep the infant isolated from others
- D. Place the infant on their back for naps
Correct Answer: C
Rationale: Bronchiolitis is a highly contagious respiratory infection commonly caused by viruses. Isolating the infant from others is crucial to prevent the spread of the infection to other vulnerable individuals, especially those with weakened immune systems. Encouraging play may not be appropriate as the infant is sick and needs rest. Limiting oral intake might be necessary if the infant is having difficulty swallowing due to respiratory distress. Placing the infant on their back for naps is a safe sleep practice but not the priority in this situation where preventing transmission of the infection is crucial.
Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?
- A. Hypertension.
- B. Gross hematuria.
- C. Proteinuria.
- D. Periorbital edema.
Correct Answer: A
Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.
What information should be reinforced with the mother of a child with ringworm (Tinea)?
- A. Ringworm is not contagious.
- B. Tinea infections are indicative of poor hygiene and uncleanliness.
- C. Tinea infections are spread by direct and indirect contact.
- D. Ringworm often subsides spontaneously.
Correct Answer: C
Rationale: The correct answer is C. Ringworm, a fungal infection, is highly contagious and can be spread by direct contact with infected individuals or animals and indirectly through contaminated objects. It is important for the mother to understand the modes of transmission to prevent the spread of the infection to others and to take necessary precautions to ensure proper treatment and containment of the condition. Choices A and D are incorrect because ringworm is indeed contagious, and it may not always subside spontaneously. Choice B is misleading as tinea infections are not solely indicative of poor hygiene; they can affect anyone, regardless of personal cleanliness.