A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

"I should not feed my baby anything for 2 hours prior to an immunization."

"I should expect my baby to have a high fever for 24 hours after an immunization."

"My baby will receive the rotavirus immunization orally

"My baby will receive three doses of the meningococcal immunization before kindergarten."

Answer and Explanation

The Correct Answer is C

The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.

There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.

While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.

The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.

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Correct Answer is A

Explanation

The correct answer is: a. Temperature 38.8° C (101.8° F)

Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.

Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.

Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.

Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.

A. Encourage the client to bathe frequently. B. Apply powder to the client's skin. C. Add moisturizing oil to the client's bath water. D. Place a humidifier in the client's room.

Correct Answer is D

Explanation

Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.

Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.

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A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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