A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
Hepatitis B (HBV)
Measles, mumps, and rubella (MMR)
Haemophilus influenzae type B (Hib)
Pneumococcal conjugate vaccine (PCV)
The Correct Answer is B
A. Hepatitis B (HBV): The Hepatitis B vaccine is typically completed in the infant stage, and a 5-year-old with up-to-date vaccinations would not need a booster for school entry. This is not included in the pre-kindergarten vaccine schedule.
B. Measles, mumps, and rubella (MMR): The MMR vaccine is part of the pre-kindergarten immunization schedule. A second dose is recommended between ages 4 and 6 to ensure immunity before school entry.
C. Haemophilus influenzae type B (Hib): The Hib vaccine is typically administered to infants and young children, and a 5-year-old with up-to-date immunizations would already be fully vaccinated against Hib. No booster is required at this age.
D. Pneumococcal conjugate vaccine (PCV): The PCV vaccine series is usually completed in infancy, and a 5-year-old with current vaccinations would not require a booster. This vaccine is not part of the pre-kindergarten schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temporal: The temporal artery is not commonly used for pulse checks in infants as it can be difficult to palpate and may not provide an accurate heart rate.
B. Carotid: The carotid pulse is not recommended in infants due to the risk of compressing the airway or carotid artery, leading to decreased blood flow to the brain.
C. Apical: The apical pulse is the most reliable method for assessing heart rate in infants. It involves auscultating the heart directly at the chest, which provides the most accurate heart rate measurement.
D. Dorsalis pedis: This site is not typically used for pulse checks in infants as it can be difficult to locate and palpate accurately.
Correct Answer is B
Explanation
A. "I will notify the doctor if his temperature is not controlled with acetaminophen." Notifying the doctor if the temperature is not controlled with acetaminophen is appropriate, as persistent fever might indicate a more severe infection or other complications.
B. "I will continue to check his blood sugar two times every day." Checking blood sugar only twice a day is insufficient during illness, especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection, and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
C. "I will report changes in breathing or signs of confusion." Reporting changes in breathing or signs of confusion is essential, as these can be signs of worsening infection, respiratory distress, or diabetic ketoacidosis, which requires immediate medical attention.
D. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes." Encouraging fluid intake is important to prevent dehydration and help manage blood glucose levels during illness. Ensuring adequate hydration with water or sugar-free fluids is appropriate.
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