Nursing Elites

1. A child receives a vaccine for MMR. Six hours after the injection, the child�s parent reports local soreness, erythema, lethargy, and a fever of 101�F to a nurse. Which action should the nurse take?

• A. Give instructions on relieving symptoms with acetaminophen
• B. Seek emergency help, because these symptoms are signs of anaphylactic reaction
• C. Tell the parent that a live vaccine will cause a mild case of measles
• D. Obtain and fill out a Vaccine Adverse Event Report form

Correct answer: A

Rationale: Low-grade fever, malaise, and muscle aches are common reactions. Acetaminophen usually alleviates these problems. MMR is a live vaccine but it is attenuated or completely avirulent and does not cause measles in healthy children, only immunocompromised children.

2. Which question does not provide information regarding the family's cultural values?

• A. Who makes the decisions?
• B. What is the child's date of birth?
• C. What are the daily routines and rules of mealtime?
• D. What do the parents believe about disability?

Correct answer: B

Rationale: The correct answer is B. Asking for the child's date of birth is a factual question that does not directly relate to the family's cultural values. Choices A, C, and D delve into aspects that could offer insights into the family's cultural values and beliefs. Question A explores decision-making dynamics within the family, which can be influenced by cultural norms. Question C inquires about daily routines and mealtime rules, which often reflect cultural practices and values. Question D relates to the parents' beliefs about disability, which can be shaped by cultural, religious, or societal perspectives. Therefore, these questions are more likely to provide information about the family's cultural values compared to the child's date of birth.

3. Which statement is not a principle of family-centered care?

• A. Respect family autonomy
• B. Provide flexible services
• C. Collaborate with family members
• D. Set strict rules for families to follow

Correct answer: D

Rationale: Family-centered care focuses on respecting family autonomy, providing flexible services, and collaborating with family members to ensure individualized care. Imposing strict rules contradicts the core principles of family-centered care, which prioritize partnership, communication, and shared decision-making between healthcare providers and families. Therefore, setting strict rules for families to follow goes against the collaborative and individualized nature of family-centered care, making it the statement that is not a principle of this approach.

4. During the oliguric phase of acute kidney injury, what intervention should be included in the plan of care for a child?

• A. Administer a loop diuretic.
• B. Provide a low-sodium diet.
• C. Weigh the child weekly.
• D. Provide a high-protein diet.

Correct answer: A

Rationale: During the oliguric phase of acute kidney injury, the priority is managing fluid balance. Administering a loop diuretic is crucial to promote diuresis and reduce fluid retention, aiding in managing the condition effectively. Providing a low-sodium diet may be beneficial but is not the priority intervention during this phase. Weighing the child weekly is important for monitoring overall health but does not directly address the oliguric phase. Providing a high-protein diet is not typically recommended in acute kidney injury, especially during the oliguric phase, as it can put additional stress on the kidneys.

5. A patient who has PUD and is receiving magnesium hydroxide (MOM) is experiencing an increased number of BM. Which is the nurse�s priority action?

• A. Ask the HCP for a reduction in dose
• B. Encourage the patient to increase dietary fiber
• C. Administer the drug with an aluminum hydroxide antacid
• D. Instruct patient to keep an accurate stool count

Correct answer: C

Rationale: MOM is a rapid-acting antacid with a prominent adverse effect of diarrhea. To compensate, it usually is administered in combo with aluminum hydroxide which promotes constipation. A reduction in dose might be necessary if the diarrhea is severe, but this is not a priority action. Increasing dietary fiber and keeping a stool count are appropriate actions to implement after adding an antacid to counteract the diarrhea effect.

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