Question

A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

Answer 1

Correct Answers:

Oxygen saturation < 90% or central cyanosis.

Rationale :

✅ Respiratory syncytial virus (RSV) can cause serious lower respiratory tract infections in infants, and signs of hypoxemia or central cyanosis require immediate intervention.

✅ An oxygen saturation <90% indicates severe impairment in oxygen exchange, placing the infant at risk for respiratory failure.

✅ Central cyanosis (blue lips or tongue) reflects inadequate oxygenation at a critical level.

✅ This is a medical emergency that demands prompt oxygen support and escalation of care.

✅ Reporting this ensures timely interventions such as hospitalization or mechanical support.

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Answer 2

Correct Answers:

Hyperpyrexia.

Rationale :

🟡 Acetylsalicylic acid (aspirin) toxicity leads to uncoupling of oxidative phosphorylation, resulting in increased body temperature (hyperpyrexia).

🟡 Other signs include tinnitus, vomiting, metabolic acidosis, and altered mental status.

🟡 Children are particularly susceptible to Reye syndrome if aspirin is used during viral infections.

🟡 Hyperpyrexia can lead to seizures or brain injury if not treated promptly.

🟡 Immediate cooling and alkalinization of urine may be part of management.

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Answer 3

Correct Answers:

Apply bactericidal ointment to lesions.

Rationale :

🟢 Impetigo is a highly contagious bacterial skin infection, most often caused by Staphylococcus aureus or Streptococcus pyogenes.

🟢 Treatment includes topical bactericidal ointments, such as mupirocin.

🟢 Systemic antibiotics may be needed if the infection is extensive or involves multiple areas.

🟢 Other hygiene measures include keeping nails short and avoiding scratching to prevent autoinoculation.

🟢 Thorough cleaning and removal of crusts before applying ointment can enhance absorption.

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Answer 4

Correct Answers:

Clear the area of hard objects.

Rationale :

🔵 During a seizure, safety is the priority—clearing the area of hard or sharp objects prevents trauma.

🔵 The child should be placed on their side to maintain an open airway but not restrained.

🔵 Inserting objects (like tongue blades) into the mouth is dangerous and can cause injury.

🔵 Once the seizure stops, the child should be reoriented and monitored.

🔵 Education should empower parents to remain calm and focused on safety.

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Answer 5

Correct Answers:

Ataxia

Rationale :

🟠 Gasoline inhalation is a type of inhalant abuse that affects the central nervous system.

🟠 A key neurologic symptom is ataxia—impaired coordination and gait disturbances.

🟠 Other symptoms may include euphoria, dizziness, confusion, and nausea.

🟠 Prolonged use can lead to permanent CNS damage and renal or hepatic dysfunction.

🟠 Assessment should include neuro status, cardiac monitoring, and urine drug screening.

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Answer 6

Correct Answers:

Creatinine 0.4 mg/dL.

Rationale :

🔴 Gentamicin is a nephrotoxic aminoglycoside, and creatinine elevation is an early indicator of renal impairment.

🔴 A creatinine level of 0.4 mg/dL is elevated for a 4-year-old (normal: 0.3–0.5 mg/dL for that age group), especially if trending upward.

🔴 The nurse must report any sign of renal compromise, as dosage adjustments or discontinuation may be required.

🔴 BUN and creatinine must be monitored throughout therapy.

🔴 Ototoxicity and nephrotoxicity are the main risks of gentamicin.

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Answer 7

Correct Answers:

Provide a pacifier coated with an oral sucrose solution prior to the injections.

Rationale :

🟣 Atraumatic care aims to reduce pain and stress during procedures, especially in infants.

🟣 Oral sucrose with pacifier has been shown to significantly reduce pain responses in infants.

🟣 EMLA cream requires 30–60 minutes to be effective, so applying it immediately is ineffective.

🟣 IM injections at 3 months should be given in the vastus lateralis, not deltoid.

🟣 Using the smallest appropriate gauge needle helps minimize pain.

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Answer 8

Correct Answers:

Bruising around the wrists.

Rationale :

⚪ Bruising in unusual areas (e.g., wrists, back, thighs) is a potential sign of non-accidental trauma.

⚪ This pattern suggests restraint injuries and should raise suspicion for physical abuse.

⚪ Common accidental bruising in children typically involves bony prominences like knees or shins.

⚪ Nurses are mandated reporters and must report suspicions of abuse to child protective services.

⚪ Documentation should be factual and detailed.

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Answer 9

Correct Answers:

"You can replace milk with nondairy sources of calcium."

Rationale :

🟤 Lactose intolerance involves difficulty digesting lactose due to low lactase enzyme levels.

🟤 Clients can meet calcium needs through nondairy sources, like broccoli, fortified orange juice, almonds, or soy products.

🟤 Yogurt with active cultures may be tolerated but varies per person.

🟤 Milk should be avoided on an empty stomach to minimize symptoms.

🟤 Education promotes symptom control and nutritional adequacy.

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Answer 10

Correct Answers:

An adolescent who has sickle cell anemia and slurred speech.

Rationale :

🟠 Slurred speech in a child with sickle cell anemia is a red flag for stroke, a known complication due to vaso-occlusion in cerebral vessels.

🟠 This is a neurological emergency that requires immediate assessment and intervention.

🟠 The other clients have concerning issues but do not present immediate life-threatening symptoms.

🟠 Prompt recognition of stroke signs improves outcomes via transfusion therapy or imaging.

🟠 The nurse should initiate a stroke protocol and notify the provider immediately.

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QLexNursing

1 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

2 :
A nurse in an emergency department is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

3 :
A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?

5 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

6 :
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of the following laboratory values should the nurse report to the provider?

7 :
A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 :
A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?

9 :
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?

QLexNursing

1 : A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

2 : A nurse in an emergency department is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

3 : A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?

4 : A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?

5 : A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

6 : A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of the following laboratory values should the nurse report to the provider?

7 : A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 : A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?

9 : A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?

10 : A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?

1 :
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the following findings to the provider?

2 :
A nurse in an emergency department is caring for a preschool-age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

3 :
A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?

4 :
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?

5 :
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?

6 :
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of the following laboratory values should the nurse report to the provider?

7 :
A nurse is preparing to administer immunizations to a 3-month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 :
A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?

9 :
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?