Nokea
A child with acute lymphoblastic leukemia (ALL) is hospitalized for treatment. What is the priority nursing intervention?
- A. Administering antibiotics
- B. Preventing infection
- C. Providing nutritional support
- D. Managing pain
Correct Answer: B
Rationale: The priority nursing intervention for a child hospitalized for acute lymphoblastic leukemia (ALL) is preventing infection. Children with ALL have compromised immune systems, making them highly vulnerable to infections. Preventing infections through strict aseptic techniques, isolation precautions, and proper hygiene is crucial to safeguard the child's health. Administering antibiotics (choice A) may be necessary if an infection occurs, but the primary focus should be on infection prevention. While providing nutritional support (choice C) is important, preventing infection takes precedence due to its direct impact on the child's survival. Managing pain (choice D) is essential for the child's comfort but is not the priority over preventing life-threatening infections in this scenario.
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During a vaccination drive at a well-child clinic, a nurse observes that a recently hired nurse is not wearing gloves. What should the nurse advise the newly hired nurse to do?
- A. Speak with the nurse manager regarding techniques.
- B. Put on gloves because standard precautions are required.
- C. Continue with the immunizations because gloves are not needed.
- D. Evaluate the child's appearance to determine whether gloves are needed.
Correct Answer: B
Rationale: The correct answer is B: "Put on gloves because standard precautions are required." Standard precautions are essential in healthcare settings to prevent the transmission of infections, and wearing gloves is a crucial part of these precautions during immunizations. Choice A is incorrect because speaking with the nurse manager about techniques does not address the immediate need for wearing gloves. Choice C is incorrect because gloves are indeed needed to prevent the spread of infections. Choice D is incorrect as evaluating the child's appearance is not a substitute for wearing gloves which are a basic infection control measure.
A 2-year-old child with a diagnosis of hemophilia is admitted to the hospital. What should the nurse include in the care plan?
- A. Encourage participation in contact sports
- B. Use a soft toothbrush for oral care
- C. Administer nonsteroidal anti-inflammatory drugs
- D. Administer aspirin for pain
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?
- A. Administering an antiviral agent
- B. Clustering care to conserve energy
- C. Offering oral fluids to promote hydration
- D. Providing an antitussive agent when necessary
Correct Answer: B
Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is to cluster care to conserve energy. Infants with RSV often have difficulty breathing and need to rest frequently. Clustering care involves grouping nursing interventions to allow for longer periods of rest between activities, which helps prevent exhaustion and conserve the infant's energy. Administering an antiviral agent is not the primary intervention for RSV, as it is a viral infection and antiviral agents are not typically used for RSV. Offering oral fluids is important for hydration but may not be the priority when the infant is struggling to breathe. Providing an antitussive agent should be done judiciously and under medical guidance, as suppressing the cough reflex can be detrimental in RSV cases where coughing helps clear airway secretions.
When caring for a neonate with a suspected tracheoesophageal fistula, what nursing care should be included?
- A. Elevating the head but giving nothing by mouth
- B. Elevating the head for feedings
- C. Feeding glucose water only
- D. Avoiding suctioning unless the infant is cyanotic
Correct Answer: A
Rationale: In a neonate with a suspected tracheoesophageal fistula, elevating the head but giving nothing by mouth is crucial to prevent aspiration. Placing the neonate in a semi-upright position helps reduce the risk of reflux and aspiration of gastric contents into the lungs. Elevating the head for feedings (Choice B) would still pose a risk of aspiration as the neonate may aspirate during feeding. Feeding glucose water only (Choice C) is not appropriate and does not address the risk of aspiration associated with a tracheoesophageal fistula. Avoiding suctioning unless the infant is cyanotic (Choice D) is incorrect because suctioning may be necessary for maintaining airway patency, regardless of cyanosis, in a neonate with a suspected tracheoesophageal fistula.
A child with a diagnosis of acute glomerulonephritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring for hypertension
- B. Providing pain relief
- C. Restricting fluid intake
- D. Encouraging fluid intake
Correct Answer: A
Rationale: The correct answer is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, potentially leading to impaired kidney function and elevated blood pressure. Monitoring for hypertension is crucial as it is a common complication of this condition. Providing pain relief (choice B) may be necessary for comfort but is not the priority. While fluid restriction (choice C) is important in some kidney conditions, in acute glomerulonephritis, maintaining adequate hydration to support kidney function is typically recommended. Encouraging fluid intake (choice D) may exacerbate fluid overload, making it an inappropriate intervention in this scenario.