Nokea
A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?
- A. Remove the child who has HIV from the foster home.
- B. Report the exposure of the child with HIV to the health department.
- C. Place the child who has HIV in reverse isolation.
- D. Review the immunization documentation of the child who has HIV.
Correct Answer: D
Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. It is important to verify the child's immunization status before considering other interventions.
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A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child's parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?
- A. We should perform CPT before meals.
- B. CPT will help loosen mucus in the lungs.
- C. We should perform CPT right after the child eats.
- D. CPT is an important part of our child's treatment.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a well-baby exam, a nurse finds that a 2-month-old's right testicle is not descended into the scrotum, but the left one is palpable. What should the nurse do?
- A. Ask if the right testis has been seen in the scrotum before
- B. Address potential concerns about future fertility
- C. Schedule an ultrasound to confirm the position of the testicle
- D. Prepare to obtain a urine specimen for culture
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 7-year-old child with a history of asthma presents to the clinic with shortness of breath and wheezing. The nurse notes that the child's peak flow reading is in the red zone. What should the nurse do first?
- A. Administer a bronchodilator
- B. Reassess the peak flow reading
- C. Notify the healthcare provider
- D. Provide oxygen therapy
Correct Answer: A
Rationale: When a child with asthma presents with shortness of breath and wheezing, and the peak flow reading is in the red zone, indicating severe airflow limitation, the priority intervention is to administer a bronchodilator. Bronchodilators help dilate the airways quickly, improving airflow and assisting with breathing. Reassessing the peak flow reading, notifying the healthcare provider, and providing oxygen therapy may be necessary actions but administering a bronchodilator takes precedence in managing acute asthma exacerbation.
A 4-year-old child is brought to the clinic with complaints of ear pain and fever. The practical nurse suspects otitis media. Which symptom supports this suspicion?
- A. Clear nasal discharge.
- B. Dry, hacking cough.
- C. Tugging at the ear.
- D. Sore throat.
Correct Answer: C
Rationale: Tugging at the ear is a common symptom in children with otitis media. It often indicates discomfort or pain in the ear, suggesting inflammation or infection in the middle ear. This behavior is frequently observed in young children who are unable to express their discomfort verbally, making it a significant clinical indicator for otitis media in this age group.
A 14-year-old client with type 1 diabetes is participating in a school sports event. The nurse provides education to the client about managing blood glucose levels during physical activity. Which statement by the client indicates a need for further teaching?
- A. I should check my blood sugar before and after exercise
- B. I need to eat a snack before I start playing
- C. If my blood sugar is high, I should skip my insulin dose before exercise
- D. I should carry a fast-acting carbohydrate with me during sports
Correct Answer: C
Rationale: The correct answer is C. Skipping insulin dose when blood sugar is high before exercise can be harmful. It is essential to manage blood glucose levels carefully during physical activity, which may require adjustments to insulin doses but skipping doses is not recommended. It is crucial to maintain blood sugar levels within the target range to prevent complications during exercise.