A 2-month-old client is brought to the well-baby clinic. The parent is completing the consent forms for routine infant immunizations. Which immunization should the practical nurse (PN) prepare to administer?
Measles Mumps Rubella (MMR).
Varicella vaccine.
Hepatitis A.
Hepatitis B.
The Correct Answer is D
A. Measles Mumps Rubella (MMR) vaccine is typically administered at 12-15 months of age, not at 2 months. It is part of the recommended immunization schedule but is not given during the 2-month visit.
B. Varicella vaccine is usually given at 12-15 months of age. It is essential for preventing chickenpox but is not included in the 2-month immunization schedule.
C. Hepatitis A vaccine is recommended starting at 12 months of age. It is not part of the immunizations administered at 2 months.
D. Hepatitis B vaccine is part of the routine immunization schedule for infants and is given at birth, 1-2 months, and 6-18 months. At the 2-month visit, it is appropriate to administer the second dose of the Hepatitis B vaccine if it was not given at 1 month.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. C-reactive protein level is a general marker for inflammation and can indicate infection, but it does not provide specific information about the wound infection.
B. Serum albumin is important for assessing nutritional status and wound healing potential, but it does not directly address the acute issue of a possible wound infection.
C. Serum blood glucose level is significant, especially in clients with diabetes, as high glucose can impair healing and increase infection risk. However, it does not directly provide information about the infection itself.
D. Culture for sensitive organisms is the most relevant lab value to evaluate before reporting to the healthcare provider. It identifies the specific pathogens causing the infection and guides appropriate antibiotic treatment.
Correct Answer is A,B,C,D
Explanation
A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.
B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.
C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.
D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.
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