Nursing Elites

1. 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.

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 healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

• A. Laughs readily, turns from back to side.
• B. Has strong Moro and tonic neck reflexes.
• C. Keeps fists clenched, opens hands when grasping an object.
• D. Can lift head, but not chest when lying on abdomen.

Correct answer: A

Rationale: The ability to laugh readily and turn from back to side indicates the effectiveness of thyroid therapy and normal development in a 5-month-old. These behaviors suggest improved muscle tone and motor skills, which are positive outcomes of thyroid hormone replacement therapy for hypothyroidism. Choices B, C, and D describe developmental milestones that are not specific indicators of the effectiveness of thyroid therapy in treating hypothyroidism in a 5-month-old.

4. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?

• A. Remove the child with HIV from the foster home.
• B. Report the exposure of the child with HIV to the health department.
• C. Place the child with HIV in reverse isolation.
• D. Review the immunization documentation of the child with HIV.

Correct answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV. This step ensures that the child has received the necessary vaccines to protect against pertussis and other preventable diseases. It is essential to verify the immunization status to provide appropriate care and prevent further transmission of infectious diseases within the foster home. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately protected through immunization. Reporting the exposure to the health department (Choice B) is important but not the first action. Placing the child in reverse isolation (Choice C) is not indicated for pertussis exposure.

5. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?

• A. Remove the child who has HIV from the foster home.
• B. Report the exposure of the child with HIV to the health department.
• C. Place the child who has HIV in reverse isolation.
• D. Review the immunization documentation of the child who has HIV.

Correct answer: D

Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. By reviewing the immunization documentation first, the nurse can determine the child's protection against pertussis and other infectious diseases. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately vaccinated. Reporting the exposure to the health department (Choice B) and placing the child in reverse isolation (Choice C) are important steps but reviewing the immunization status takes precedence to assess the child's protection and guide further actions.

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