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A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.
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A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.
A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?
- A. A school-age child who has viral conjunctivitis
- B. A preschool-age child who has pediculosis capitis
- C. A toddler who has seasonal influenza
- D. An adolescent who has hepatitis A
Correct Answer: C
Rationale: The correct answer is C: A toddler who has seasonal influenza. Droplet precautions are required for diseases transmitted via respiratory droplets, such as influenza. Seasonal influenza is highly contagious through respiratory secretions, making it crucial to prevent transmission. The other choices do not require droplet precautions: A - viral conjunctivitis is spread through direct contact with eye secretions, B - pediculosis capitis (head lice) is spread through direct head-to-head contact, and D - hepatitis A is primarily spread through the fecal-oral route. Therefore, C is the correct choice for droplet precautions.
A nurse is teaching a group of parents about childhood immunization. The nurse should identify that infants should receive the first dose of which of the following immunizations at 12 months of age?
- A. Inactivated poliovirus
- B. Human papillomavirus
- C. Hepatitis B
- D. Varicella
Correct Answer: D
Rationale: The correct answer is D: Varicella. Infants should receive the first dose of varicella vaccine at 12 months of age to prevent chickenpox. Varicella is highly contagious and can lead to serious complications in children. The other choices are incorrect because:
A: Inactivated poliovirus - The first dose of polio vaccine is typically given at 2 months of age.
B: Human papillomavirus - HPV vaccine is usually recommended for adolescents, not infants.
C: Hepatitis B - Hepatitis B vaccine is usually given shortly after birth, not at 12 months of age.
In summary, varicella is the appropriate immunization for infants at 12 months to protect them from chickenpox, while the other options are administered at different ages or for different diseases.
A nurse is assessing a 7-year-old child who has diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Increased capillary refill
- B. Thirst
- C. Shakiness
- D. Decreased appetite
Correct Answer: C
Rationale: The correct answer is C: Shakiness. Hypoglycemia in a child with diabetes can lead to a decrease in blood sugar levels, causing symptoms like shakiness due to the body's response to low glucose levels. Increased capillary refill (A) is not typically associated with hypoglycemia. Thirst (B) is more commonly seen in hyperglycemia. Decreased appetite (D) can be a symptom of hypoglycemia, but shakiness is a more specific indicator.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.