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A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?
- A. Haemophilus influenza type b (Hib)
- B. Inactivated poliovirus (IPv)
- C. Hepatitis B (HepB)
- D. Influenza
Correct Answer: D
Rationale: The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years. The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease. The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver. The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin.
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A nurse at a pediatrician's office answers a phone call from a parent whose child just ingested 15 vitamin tablets with added ferrous sulfate. Which of the following instructions should the nurse give to the parent?
- A. Administer syrup of ipecac.
- B. Give the child 120 mL (8 oz) of orange juice.
- C. Contact the poison control center.
- D. Provide the child with a high-carbohydrate snack.
Correct Answer: C
Rationale: Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness. Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body. Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose. Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms' tumor. Which of the following symptoms should the nurse anticipate?
- A. Jaundice
- B. Abdominal mass
- C. Swollen joints
- D. Diarrhea
Correct Answer: B
Rationale: Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms' tumor. It is more commonly associated with conditions that cause liver dysfunction. An abdominal mass is one of the most common symptoms of Wilms' tumor. Parents or healthcare providers may feel a lump or swelling in the child's abdomen. Swollen joints are not a typical symptom of Wilms' tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis. Diarrhea is not a typical symptom of Wilms' tumor. It is more commonly a symptom of gastrointestinal illnesses.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
- A. Maintain a saline-lock.
- B. Place the child on a no-salt-added diet.
- C. Check the child's weight daily.
- D. Educate the parents about potential complications.
Correct Answer: C
Rationale: While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. This is the correct answer. Checking the child's weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions. Educating the parents about potential complications is important, but it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications.
A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?
- A. Yogurt
- B. Gelatin
- C. Strained soup
- D. Pureed fruit
Correct Answer: B
Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperactive bowel sounds
- C. WBC 17,000/mm
- D. Left lower quadrant abdominal pain
Correct Answer: C
Rationale: Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body's response to inflammation and infection. Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process. A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis. Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.