Nursing Elites

1. A 3-year-old child is admitted to the hospital with a diagnosis of Kawasaki disease. What is the priority nursing intervention?

• A. Administering IV immunoglobulin
• B. Monitoring for coronary artery aneurysms
• C. Encouraging fluid intake
• D. Providing nutritional support

Correct answer: B

Rationale: The priority nursing intervention for a 3-year-old child with Kawasaki disease is monitoring for coronary artery aneurysms. Kawasaki disease can lead to the development of coronary artery aneurysms, which are one of the most serious complications of the disease. Early detection and monitoring of coronary artery changes are essential for prompt intervention and prevention of adverse outcomes. Administering IV immunoglobulin is an important treatment for Kawasaki disease, but monitoring for coronary artery aneurysms takes precedence as it directly impacts the child's long-term prognosis. Encouraging fluid intake and providing nutritional support are important aspects of care but are not the priority when compared to monitoring for potential life-threatening complications.

2. What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele?

• A. Positioning the infant supine with a pillow under the buttocks
• B. Covering the sac with saline-soaked nonadhesive gauze
• C. Wrapping the infant snugly in a blanket
• D. Applying a diaper to prevent fecal soiling of the sac

Correct answer: B

Rationale: The correct answer is B: Covering the sac with saline-soaked nonadhesive gauze. This intervention is essential in caring for an infant with myelomeningocele as it helps prevent infection and maintains a moist environment around the sac before surgical repair. Positioning the infant supine with a pillow under the buttocks (Choice A) may be suitable for comfort but is not directly related to managing the myelomeningocele. Wrapping the infant snugly in a blanket (Choice C) and applying a diaper (Choice D) are not recommended as they can increase the risk of infection and damage to the sac.

3. A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant’s discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?

• A. It should not be given until the infant reaches 2 years of age.
• B. Infants who are receiving chemotherapy should not be given these vaccines.
• C. It should be given to protect the infant from contracting any of these diseases.
• D. The parents should discuss this with their healthcare provider at the next visit.

Correct answer: B

Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.

4. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?

• A. Thickened formula 24 hours after surgery
• B. Withholding feedings for the first 24 hours
• C. Regular formula feeding within 24 hours after surgery
• D. Additional glucose feedings as desired after the first 24 hours

Correct answer: C

Rationale: After surgery for hypertrophic pyloric stenosis (HPS), it is appropriate to resume regular formula feeding within 24 hours postoperatively to promote recovery. Choice A, thickened formula after surgery, may be too heavy for the infant's digestive system at this early stage. Withholding feedings for the first 24 hours (Choice B) is not recommended as early feeding helps with recovery. Additional glucose feedings (Choice D) are not necessary and may not provide the balanced nutrition required after surgery.

5. A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?

• A. Recommend raising the bed's side rails when a caregiver is not present.
• B. Suggest a caregiver be present continuously to prevent falls from bed.
• C. Encourage the use of loose restraints while in bed.
• D. Recommend raising the bed's side rails throughout the day and night.

Correct answer: A

Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.

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