A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following clients?
A 2-month-old infant
A 4-month-old infant
A 6-month-old infant
A 15-month-old toddler
The Correct Answer is A
The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough).
The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.
The other options are incorrect because:
b) A 4-month-old infant: By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.
c) A 6-month-old infant: By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.
d) A 15-month-old toddler: By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.
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Related Questions
Correct Answer is C
Explanation
When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.
The other options are not recommended for instillation of nasal drops for various reasons:
a) Sims position: Simsposition is a side-lying position with the upper leg flexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.
b) Prone position: Prone position refers to lying face down. It is not ideal for administering nasal drops as it
can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.
d) Orthopneic position: Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.

Correct Answer is B
Explanation
b. Keep suction equipment at the client's bedside.
The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.
Explanation for the other options:
a. Restrict the client's fluid intake: Restricting the client's fluid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific fluid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.
c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-flexed posture and a shuffling gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.
d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reflux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.

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