After the first injection of the Hepatitis B Vaccine (HBV) series is administered to a group of healthcare workers, what advice should the nurse give to them?

Answer and explanation The correct answer is D. Choice A rationale

Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.

Choice B rationale

Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.

Choice C rationale

Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.

Choice D rationale

Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.

Answer and explanation The correct answer is B. Choice A rationale

Fitting a prosthetic device requires specialized knowledge and skills that a home health aide may not possess. This task should be performed by a healthcare professional with appropriate training.

Choice B rationale

Evaluating the need for an elevated toilet seat involves assessing the client’s mobility and safety in the bathroom, tasks that a home health aide could perform under the supervision of a nurse.

Choice C rationale

Performing a sterile dressing change is a complex task that requires specific nursing knowledge and skills. It should not be delegated to a home health aide.

Choice D rationale

Assessing a pressure sore involves making judgments about the client’s skin integrity and the effectiveness of treatment strategies. This is a nursing responsibility and should not be delegated to a home health aide.