A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

Administer children's aspirin to help prevent inflammation.

Keep the infant home from daycare for the next two days.

Any level of fever is serious and should be reported right away.

Apply a cool pack to the injection site to reduce discomfort.

Answer and Explanation

The Correct Answer is D

Rationale

A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.

B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.

C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.

D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.

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Correct Answer is D

Explanation

Rationale

A. While ensuring the room is secure and providing one-on-one observation are also important, the immediate concern after administering haloperidol is the potential for these side effects.

B. Continuous observation is crucial to monitor the client's behavior, mood, and safety while in seclusion. This allows the nurse to intervene promptly. However, monitoring should be specific

C. Seclusion is not intended as a punishment but as a therapeutic intervention to protect the client and others from harm during acute psychiatric episodes. The decision to release the client should be based on clinical assessment

D. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms (EPS), including dystonia (muscle spasms). Monitoring for EPS is essential after administering haloperidol to ensure early detection and treatment, which may involve administering anticholinergic medications if EPS occurs.

A. Assess for symmetrical chest movement.<br> B. Auscultate for presence of bilateral breath sounds. C. Obtain a portable chest x-ray to verify ETT location. D. Monitor ETT markings between 22 and 26 cm at teeth line. E. Check for capillary refill of 3 seconds or less.

Correct Answer is ["A","B","C"]

Explanation

Rationale

A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.

B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.

C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.

This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.

E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.

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A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?