Nursing Elites

1. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?

• A. Chewable children’s aspirin will not help prevent inflammation.
• B. Keep the child home for the next two days.
• C. Any fever should be monitored and reported if severe.
• D. Apply a cool pack to the injection site to reduce discomfort.

Correct answer: D

Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.

2. What advice is most important for a client in the first trimester of pregnancy experiencing nausea?

• A. Practice relaxation techniques when nausea begins.
• B. Increase fluid intake to 3 quarts daily.
• C. Avoid alcohol, caffeine, and smoking.
• D. Eliminate snacks between meals.

Correct answer: C

Rationale: During the first trimester of pregnancy, it is crucial to advise pregnant clients to avoid alcohol, caffeine, and smoking. These substances can worsen nausea and harm fetal development. By eliminating these substances, the client can help alleviate nausea and create a healthier environment for the developing fetus. Choices A, B, and D are not as critical in managing nausea during the first trimester. While relaxation techniques may help, avoiding harmful substances like alcohol, caffeine, and smoking takes precedence. Increasing fluid intake can be beneficial but not as crucial as avoiding harmful substances. Eliminating snacks between meals may not be necessary for all clients and is not directly related to managing nausea in the first trimester.

3. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?

• A. Notify the healthcare provider immediately.
• B. Suction the infant's nares, then the oral cavity.
• C. Check the infant's oxygen saturation rate.
• D. Position the infant on the right side.

Correct answer: C

Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.

4. The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse calculates that the woman's next fertile period is

• A. January 14-15.
• B. January 22-23.
• C. January 30-31.
• D. February 6-7.

Correct answer: C

Rationale: To determine the fertile period, subtract 14 days from the length of the woman's menstrual cycle. In this case, 36-14 = 22. Counting forward from the first day of the last menstrual period (January 8), the fertile period falls around January 30-31. This is because ovulation typically occurs approximately 14 days before the start of the next menstrual period, marking the fertile window for conception.

5. A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?

• A. Refer the mother to the Centers for Disease Control and Prevention.
• B. Report the incident to the school principal.
• C. Culture the bite site when the child returns to school.
• D. Schedule a test for Lyme disease if a rash appears.

Correct answer: D

Rationale: The correct action to take in this situation is to schedule a test for Lyme disease if a rash appears. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom of the disease. Testing for Lyme disease is crucial for timely diagnosis and treatment to prevent complications. Referring the mother to the Centers for Disease Control and Prevention (Choice A) is not necessary at this point, as immediate testing for Lyme disease is more appropriate. Reporting the incident to the school principal (Choice B) is not the most direct action to address the potential health concern. Culturing the bite site when the child returns to school (Choice C) may not be as effective as scheduling a test for Lyme disease if a rash appears, as the latter is a more specific diagnostic measure for Lyme disease.

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