Nursing Elites

1. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?

• A. Hib
• B. IPV
• C. MMR
• D. DTaP

Correct answer: D

Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.

2. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

• A. "I am nervous about how painful labor will be."?
• B. "I need to review my finances and make sure I am prepared to care for a child."?
• C. "I hate this nausea that I've been having for a week."?
• D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?

Correct answer: D

Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

3. The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?

• A. "I will hold my breath for 10 seconds after each puff."?
• B. "I will wait five minutes after taking this medication and then gargle water."?
• C. "I will wait at least one minute between each puff."?
• D. "I will take this medication daily even if I am not having symptoms."?

Correct answer: B

Rationale: The correct answer is, 'I will wait five minutes after taking this medication and then gargle water.' After using an inhaled glucocorticoid, it is essential to wait for 5 minutes and then gargle water to remove any residue from the mouth, which can reduce the risk of developing thrush, a fungal infection. Choice A is correct as holding the breath for 10 seconds after each puff helps the medication reach deep into the lungs. Choice C is also correct as waiting at least one minute between puffs ensures proper delivery of the medication. Choice D is incorrect because it is important to take the medication daily as prescribed to control asthma symptoms, even if the person is not experiencing any at that moment.

4. Health promotion activities are designed to help clients:

• A. reduce the risk of illness
• B. maintain maximal function
• C. promote healthy habits related to healthcare
• D. all of the above

Correct answer: D

Rationale: Health promotion activities encompass a broad range of interventions aimed at enhancing overall well-being. These activities not only focus on reducing the risk of illness but also on maintaining maximal function and promoting healthy habits related to healthcare. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all integral components of health promotion strategies, emphasizing the multidimensional approach required to support clients in achieving optimal health outcomes.

5. A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

• A. Administering an intravenous (IV) opioid analgesic
• B. Assisting the woman in taking a warm sitz bath
• C. Applying an ice pack to the perineum
• D. Contacting the registered nurse

Correct answer: C

Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.

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