The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?

Correct Answer: D

Rationale: The correct answer is D: Do not expose other children. RSV is very contagious even without direct oral contact. Rationale: RSV is highly contagious and can spread through respiratory droplets, making it important to prevent exposing other children to the virus. Even without direct oral contact, the virus can be transmitted. Therefore, it is crucial to avoid putting other children at risk of contracting RSV. Summary of other choices: A: Wearing a mask may not be practical for an infant and may not provide sufficient protection against RSV transmission. B: RSV can still be contagious for several days after symptoms appear, so the child may still be able to spread the virus. C: While avoiding infants under 6 months can be a good precaution, all children should be protected from exposure to RSV due to its high contagiousness.

Correct Answer: D

Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm. A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation. B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation. C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.

Correct Answer: B

Rationale: The correct answer is B: Encourage the client to schedule a digital rectal exam. This option is correct because the client's symptoms of nocturia, weak urine flow, and difficulty initiating urine stream suggest potential prostate issues, such as benign prostatic hyperplasia (BPH). A digital rectal exam can help assess the size and condition of the prostate gland. It is an essential step in diagnosing BPH or other prostate conditions. Other choices are incorrect because: A: Obtaining a urine specimen for culture and sensitivity is not the priority in this case, as the client's symptoms are more indicative of a prostate issue rather than a urinary tract infection. C: Maintaining a voiding diary may provide information on the frequency and volume of urine output, but it does not address the underlying cause of the client's symptoms. D: Instructing the client in cleansing techniques for the glans penis is not relevant to the reported symptoms and does not address the potential prostate issue.

Correct Answer: C

Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention. Incorrect choices: A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding. B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action. D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.

Correct Answer: D

Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications. Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic. Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications. Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.