Nokea
A child with a peanut allergy is prescribed an epinephrine auto-injector. The nurse should teach the parents to administer it in which situation?
- A. Mild itching after eating peanuts.
- B. Swelling of the lips and tongue.
- C. Upset stomach after exposure.
- D. Fatigue after a meal.
Correct Answer: B
Rationale: Lip and tongue swelling indicates anaphylaxis, requiring immediate epinephrine. Itching, upset stomach, or fatigue are less severe and managed differently.
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When developing the teaching plan for the mother of a 2-year-old child diagnosed with babies, which do not be the following points should the nurse expect to include?
- A. The floors of the house should be cleaned with a damp mop.
- B. The child should be held frequently.
- C. Itching should cease in a few days.
- D. The entire family should be treated.
Correct Answer: D
Rationale: The question likely refers to scabies (miswritten as 'babies'). Scabies requires treatment of all household members to prevent reinfestation. Damp mopping is less relevant, frequent holding may spread mites, and itching may persist post-treatment.
A parent asks why it is recommended that the second dose of the measles, mumps, and rubella (MMR) vaccine be given at 4 to 6 years of age? The nurse should explain to the parent that the second dose is given at this age for what reason?
- A. If the child has not developed immunity and becomes pregnant when receiving the vaccine, the risks to the fetus are high.
- B. The chance of contracting the disease is much lower at this age.
- C. The dangers associated with a strong reaction to the vaccine are increased at this age.
- D. A serious complication from the vaccine is swelling of the joints.
Correct Answer:
Rationale: The second MMR dose ensures long-term immunity, as some children may not respond fully to the first dose.
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply.
- A. Coughing.
- B. Respiratory rate of 35 breaths/minute.
- C. Heart rate of 95 beats/minute.
- D. Restlessness.
- E. Malaise.
- F. Diaphoresis.
Correct Answer: B,D,F
Rationale: A respiratory rate of 35 breaths/minute (elevated for a toddler), restlessness, and diaphoresis indicate respiratory distress, reflecting increased work of breathing and stress. Coughing may be present but is less specific, while a heart rate of 95 bpm and malaise are not directly indicative of acute respiratory distress.
A mother asks, "How should I bathe my baby now that he's had surgery for his inguinal hernia?" Which of the following instructions should the nurse give the mother?
- A. Clean his face and diaper area for 2 weeks.
- B. Use sterile sponges to cleanse the inguinal incision.
- C. Give him a sponge bath daily for 1 week.
- D. Give the infant full tub baths every day.
Correct Answer: C
Rationale: Sponge baths for 1 week keep the incision dry and reduce infection risk.
Which of the following should the nurse include in the discharge teaching for a parent of an infant with a repaired cleft lip to promote healing?
- A. Avoid pacifier use for 2 weeks.
- B. Apply antibiotic ointment daily.
- C. Keep the infant in a supine position.
- D. Offer large, frequent feedings.
Correct Answer: A
Rationale: Avoiding pacifier use prevents stress on the suture line, promoting healing.