Nursing Elites

1. When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?

• A. Reduce fever.
• B. Maintain fluid and electrolyte balance.
• C. Prevent cardiac damage.
• D. Maintain joint mobility and function.

Correct answer: C

Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever. Therefore, choices A, B, and D are not the primary goals of nursing care in this case.

2. A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child’s plan of care?

• A. Obtain vital signs to monitor for fluid overload
• B. Change IV site dressing every 3 days and as needed
• C. Monitor for signs of facial swelling or urticaria
• D. Assess for abdominal pain and vomiting

Correct answer: C

Rationale: Monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial when administering antibiotics like azithromycin. It is important to watch for these signs to promptly identify and manage any potential adverse reactions during the course of treatment.

3. The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

• A. Has doubled birth weight.
• B. Turns head to locate sound.
• C. Plays peek-a-boo.
• D. Demonstrates startle reflex.

Correct answer: D

Rationale: At 6 months old, the startle reflex should diminish, so its persistence warrants further evaluation by the nurse. Choices A, B, and C are appropriate developmental milestones for a 6-month-old infant. By 6 months, infants typically double their birth weight, exhibit localization of sound by turning their head, and engage in interactive play like peek-a-boo.

4. The mother of a 9-month-old, diagnosed with respiratory syncytial virus (RSV) yesterday, calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?

• A. The child will no longer be contagious, so no need to take any further precautions.
• B. Ensure there are no children under the age of 6 months around the infected child.
• C. The child can be around other children but should wear a mask at all times.
• D. Do not expose other children to RSV. It is highly contagious even without direct contact.

Correct answer: D

Rationale: The correct answer is D. RSV is highly contagious, even without direct contact. It is important to prevent the spread of the virus to other children, so the infected child should not attend the birthday party to avoid exposing other children to RSV. This is crucial to protect the health of other children who may be more vulnerable to the virus. Choices A, B, and C are incorrect. Choice A is incorrect as RSV remains contagious for a period of time, and precautions should be taken to prevent its spread. Choice B is incorrect because the age limit specified is not a reliable measure to prevent transmission. Choice C is incorrect as wearing a mask may not be sufficient to prevent the spread of RSV in a social setting like a birthday party.

5. A 6 year old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings, what actions should the nurse take first?

• A. Administer a prescribed bronchodilator.
• B. Encourage the child to cough and deep breath.
• C. Report findings to the health care provider.
• D. Determine what triggers precipitated this attack.

Correct answer: A

Rationale: Administering a bronchodilator will help open the airways and improve breathing.

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