After 3 days, the nurse notes that James has chest indrawing and stridor. His mother returned him to the health center immediately. The nurse should:
- A. Change the antibiotic to second-line antibiotics
- B. Advise the mother to observe the child and continue giving the antibiotics
- C. Give the first dose of antibiotics and refer urgently
- D. Observe the child at the center
Correct Answer: C
Rationale: Chest indrawing and stridor are signs of severe respiratory distress. In this situation, immediate referral is essential. Giving the first dose of antibiotics before referral can help initiate treatment, but urgent referral for further evaluation and management is crucial. Choice A is incorrect because simply changing the antibiotic without assessing the severity of the symptoms and providing urgent care is not appropriate. Choice B is incorrect as advising the mother to observe the child and continue antibiotics delays necessary intervention for a potentially life-threatening condition. Choice D is incorrect as observing the child at the center is not sufficient when signs of severe illness are present.
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When a nurse from the surgical department is reassigned to the pediatric unit, the charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
- A. Congenital cardiac defects
- B. An acute febrile illness
- C. Prolonged hypoxemia
- D. Severe multiple trauma
Correct Answer: C
Rationale: The correct answer is C, 'Prolonged hypoxemia.' Prolonged hypoxemia is a critical condition that requires specialized pediatric care due to the high risk of cardiac arrest. The other choices, such as congenital cardiac defects, acute febrile illness, and severe multiple trauma, may also require attention, but prolonged hypoxemia poses the highest risk for cardiac arrest and demands specialized expertise in managing pediatric patients with this condition.
The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the CDC?
- A. 13-18 years of age
- B. 11-12 years of age
- C. 18-24 months of age
- D. 4-6 years of age
Correct Answer: D
Rationale: The correct answer is D: 4-6 years of age. The CDC recommends administering the MMR booster to children aged 4 to 6 years. This booster dose is essential to ensure continued immunity against measles, mumps, and rubella. Choices A, B, and C are incorrect because they do not align with the CDC guidelines for the age range of MMR booster administration.
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?
- A. Positive Homan's sign
- B. Fever and chills
- C. Dyspnea and cough
- D. Sensory impairment
Correct Answer: C
Rationale: The correct answer is C: 'Dyspnea and cough.' Pulmonary embolism often presents with a sudden onset of dyspnea (difficulty breathing) and cough, which are due to the obstruction of blood flow in the pulmonary arteries. Choices A, B, and D are incorrect. Positive Homan's sign is associated with deep vein thrombosis, fever and chills are nonspecific symptoms commonly seen in infective endocarditis, and sensory impairment is not typically indicative of pulmonary embolism.
In the preparation of your health education plan, what is the first thing to do?
- A. Assess community needs for health education
- B. Identify the subjects for health teaching
- C. Specify your goals and objectives
- D. Identify who will provide support and the type of support to be provided
Correct Answer: A
Rationale: The correct answer is A: Assess community needs for health education. This is the initial step in developing a health education plan as it helps in understanding the specific requirements of the community. Identifying subjects for teaching (choice B) comes after assessing needs. Specifying goals and objectives (choice C) is crucial but typically follows the assessment of community needs. Identifying support providers and types (choice D) is important but is not the first step in preparing a health education plan.
A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:
- A. Increase acid secretion
- B. Reduce acid secretion
- C. Promote gastric emptying
- D. Remove the ulcerated area
Correct Answer: B
Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.