Nokea
In an immunization clinic, which patient will the nurse identify as not eligible to receive routine immunizations?
- A. An 8-year-old experiencing diarrhea
- B. A 2-year-old with a history of pre-term birth
- C. A 4-year-old with a fever and upper respiratory tract infection
- D. A 6-year-old who has been recently exposed to a classmate with chickenpox
Correct Answer: C
Rationale: The nurse should identify the 4-year-old with a fever and upper respiratory tract infection as not eligible to receive routine immunizations. It is contraindicated to administer vaccines in the presence of moderate to severe illness, whether with or without fever, to prevent potential complications or reduced vaccine efficacy.
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What is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery?
- A. Covering the exposed intestines with sterile moist gauze
- B. Wrapping the newborn warmly in two or three blankets
- C. Providing sterile water feeding to maintain hydration during transport
- D. Allowing the parents of the newborn to see their child prior to transport
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?
- A. Risk for Injury related to hypertension.
- B. Altered Growth and Development related to chronic disease.
- C. Risk for Infection related to hypertension.
- D. Fluid Volume Excess related to decreased plasma filtration.
Correct Answer: A
Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.
A four-year-old patient, whose family follows a strict vegetarian diet, undergoes a prekindergarten physical examination. The pediatric nurse is alert to the patient's potential deficiency of:
- A. niacin.
- B. thiamin.
- C. vitamin B6.
- D. vitamin B12.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 5-year-old child, recently diagnosed with ileocecal Burkitt lymphoma; lab investigations reveal: serum uric acid 12 mg/dl, serum sodium, 145 meq/dl; serum potassium, 4.5 meq/dl; serum phosphate 4.4 meq/dl; serum calcium, 8.9 mg/dl; blood urea, 22 mg/dl; serum creatinine, 0.8 mg/dl. Of the following, the MOST effective treatment is
- A. excessive hydration
- B. sodium bicarbonate
- C. xanthine oxidase inhibitor
- D. recombinant urate oxidase
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During an assessment, which manifestation should a healthcare provider expect in an infant with pyloric stenosis?
- A. Bile-stained vomitus
- B. Distended abdomen
- C. Olive-shaped mass in the upper abdomen
- D. Painless, swollen joints
Correct Answer: C
Rationale: Pyloric stenosis in infants typically presents with an olive-shaped mass in the upper abdomen due to hypertrophy of the pyloric muscle. This mass can often be palpated during an assessment and is a key characteristic of this condition. Bile-stained vomitus may be seen in conditions such as intestinal obstruction; a distended abdomen can be a nonspecific sign of various conditions, and painless, swollen joints are not typically associated with pyloric stenosis.