Nursing Elites

1. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?

• A. measles, polio, pertussis, hepatitis B
• B. diphtheria, pertussis, polio, tetanus
• C. rubella, polio, pertussis, hepatitis A
• D. measles, mumps, rubella, polio

Correct answer: B

Rationale: By 12 months of age, children should have received the DTaP (diphtheria, pertussis, and tetanus) vaccine along with the polio vaccine. The MMR (measles, mumps, and rubella) vaccine is not typically given until the child is 12-15 months old. Therefore, option B is correct as it includes vaccines that are usually administered by 12 months of age. Options A, C, and D are incorrect as they include vaccines that are typically given after 12 months of age.

2. A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse's next action?

• A. Document the client's concern in the medical record.
• B. Report the client's concern to the health care provider.
• C. Tell the client that sexual dysfunction is not a normal age-related change.
• D. Ask the client about medications he is taking.

Correct answer: D

Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.

3. A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?

• A. Prone
• B. Standing
• C. Supine
• D. Hands and knees

Correct answer: D

Rationale: During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.

4. The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?

• A. Allow the child to chew on a cooled teething ring.
• B. Massage the child's gums gently.
• C. Administer acetaminophen.
• D. Administer aspirin.

Correct answer: D

Rationale: Administering aspirin would be inappropriate in this situation. Aspirin should not be recommended for children due to the increased risk of Reye's syndrome, a serious condition. Choices A, B, and C are all appropriate measures for managing teething discomfort in infants. Allowing the child to chew on a cooled teething ring can help soothe the gums, massaging the child's gums gently can provide relief, and administering acetaminophen is a suitable option for pain relief in infants with teething discomfort. Aspirin is contraindicated in children with viral infections due to the risk of Reye's syndrome, a potentially fatal condition affecting the brain and liver. Therefore, recommending aspirin to the mother would not be appropriate in this case.

5. The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?

• A. 100 mL/hr
• B. 150 mL/hr
• C. 200 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.

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