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?

Correct Answer: A

Rationale: The correct action for the nurse to take in this scenario is to give instructions on relieving symptoms with acetaminophen (Option A). This is the appropriate response because the symptoms described by the parent - local soreness, erythema, lethargy, and a low-grade fever - are common and expected side effects following a vaccine administration, particularly the MMR vaccine. These symptoms are typically mild and can be managed with supportive care, such as acetaminophen for fever and discomfort. Option B, seeking emergency help for signs of anaphylactic reaction, is incorrect in this case as the symptoms presented are not indicative of a severe allergic reaction. Option C is also incorrect as it provides inaccurate information about live vaccines causing a mild case of measles, which is not true for the MMR vaccine. Option D, filling out a Vaccine Adverse Event Report form, is not necessary at this point as the symptoms are within the expected range for a vaccine reaction and do not warrant reporting as an adverse event. From an educational perspective, it's important for nurses to be able to differentiate between common, mild vaccine reactions and more serious adverse events. Understanding the expected side effects of vaccines and how to manage them is crucial in providing safe and effective care to pediatric patients. Nurses should also be able to educate parents about normal post-vaccination symptoms and when to seek further medical attention.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Potassium. When a patient is taking glucocorticoids and digoxin, the nurse should prioritize monitoring potassium levels. Glucocorticoids can cause potassium depletion, leading to hypokalemia. Digoxin, on the other hand, can cause toxicity, especially in the presence of low potassium levels, which can potentiate its effects on the heart and increase the risk of serious cardiac arrhythmias. A) Calcium is not the most critical electrolyte to monitor in this case. While it is important for muscle and nerve function, it is not directly affected by the combination of glucocorticoids and digoxin. B) Magnesium is also important for muscle and nerve function, but it is not the priority electrolyte to monitor when a patient is taking glucocorticoids and digoxin. C) Sodium levels are typically not significantly impacted by glucocorticoids and digoxin in a way that would necessitate prioritizing monitoring compared to potassium in this specific scenario. Educationally, understanding the interactions between medications and electrolyte imbalances is crucial for pediatric nurses. This knowledge helps in providing safe and effective care to pediatric patients, especially those on multiple medications with potential interactions. Prioritizing monitoring based on these interactions can prevent complications and improve patient outcomes.

Correct Answer: B

Rationale: The patient is exhibiting symptoms of anaphylaxis triggered by a peanut allergy, which is a severe and potentially life-threatening allergic reaction. The appropriate medication for anaphylaxis is epinephrine. Epinephrine acts quickly to reverse the symptoms by constricting blood vessels, relaxing bronchial muscles, and reducing laryngeal edema, making it the drug of choice for this situation. Promethazine, diphenhydramine, and hydroxyzine are not the first-line treatments for anaphylaxis and may not address the severe manifestations seen in this case.

Correct Answer: B

Rationale: In this scenario, the most important question for the nurse to ask the patient with Parkinson's disease who is taking levodopa/carbidopa (Sinemet) is option B: "Are you having vivid dreams or hallucinations?" This question is crucial because levodopa, a common medication for Parkinson's disease, can lead to side effects such as vivid dreams or hallucinations. It is essential for the nurse to assess for these symptoms as they can impact the patient's overall well-being and quality of life. Option A, asking about swelling in the feet, is less relevant in this case as it is not a common side effect of levodopa/carbidopa. Option C, inquiring about changes in stool, is also less important as it is not directly related to the medication or the management of Parkinson's disease. Option D, asking about the flu vaccine, while important for overall health, is not as pertinent during a semi-annual physical examination specifically for a patient with Parkinson's disease on levodopa/carbidopa. Educationally, this question highlights the importance of understanding common side effects of medications used to treat specific conditions. It emphasizes the need for nurses to be knowledgeable about potential medication side effects and to prioritize assessments based on the specific medications and conditions their patients have. This rationale underscores the significance of comprehensive patient assessments in providing safe and effective care.

Correct Answer: A

Rationale: The correct answer is A. Isotretinoin is highly teratogenic, which means it can cause birth defects. Therefore, it is crucial for patients, especially females of childbearing potential, to use effective forms of birth control to prevent pregnancy while taking this medication. This is a key component of patient teaching to ensure the safe use of isotretinoin.