Nokea
The nurse advises the parents that the child is due to receive which of the following immunization boosters?
- A. Haemophilus influenzae type b (Hib)
- B. Polio
- C. Smallpox
- D. Tetanus
Correct Answer: D
Rationale: A 14-year-old is due for a tetanus-diphtheria-pertussis (Tdap) booster, typically recommended at 11-12 years if not received since age 6, to maintain immunity.
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The nurse is caring for a preterm infant with respiratory distress syndrome (RDS). Which intervention should the nurse implement to maximize the infant’s respiratory status?
- A. Check blood glucose levels every 4 hours.
- B. Cool and humidify all inspired gases.
- C. Weigh the infant every other day.
- D. Place the infant in a prone position.
Correct Answer: D
Rationale: The prone position improves oxygenation in collapsed alveoli for RDS infants with cardiorespiratory monitoring. Glucose checks cold gases and infrequent weighing don’t aid respiration.
The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C)? Select all that apply.
- A. Carefully dry the infant immediately after birth.
- B. Place the infant skin-to-skin with the mother.
- C. Apply leggings to both of the newborn’s legs.
- D. Cover the infant’s head with a stocking cap.
- E. Place the infant in a bassinette close to the wall.
Correct Answer: A,B,D
Rationale: Drying the newborn prevents heat loss through evaporation. Skin-to-skin contact with the mother assists in maintaining body temperature. A stocking cap conserves heat. Leggings are unnecessary and placing the bassinette near a wall causes radiation heat loss.
When teaching an adolescent male client about testicular self-examination, which instruction should the nurse include?
- A. Have examination after a warm bath or shower.
- B. Report any difference in the size of your testicles to the physician.
- C. Malignant lumps are usually located on the front side of the testicles.
- D. Both testicles should be examined simultaneously to detect differences.
Correct Answer: A
Rationale: Performing testicular self-examination after a warm bath or shower relaxes the scrotum, making it easier to detect abnormalities, a key instruction for effective screening.
Which information about methamphetamine use is most accurate and important for the parents to know?
- A. Methamphetamines are tried by most adolescents and cause no harm.
- B. Methamphetamines are known to lead to addiction.
- C. Methamphetamines are a central nervous system depressant.
- D. Methamphetamines are harmful only if taken intravenously.
Correct Answer: B
Rationale: Methamphetamines are highly addictive stimulants, and informing parents about the risk of addiction is critical to understanding the severity of the adolescent's behavior.
Which of the following test is used in screening for Down's syndrome:
- A. Ca 125.
- B. Carcino embryonic antigen CAE.
- C. Triple screening including β HCG,AFP,serum estriol.
- D. FSH,LH.
- E. Thyroid hormone.
Correct Answer: C
Rationale: The triple screen (β-hCG AFP serum estriol) is used in the second trimester to screen for Down syndrome. Other tests are not relevant for this purpose.