During a well-check for a 12-month-old, the nurse plans to administer the first dose of the varicella vaccine. What is an appropriate action for the nurse to take?

Delay the immunization if the child presents with nasopharyngitis.

Evaluate for presence of allergies to vaccine components.

Refrain from administering since the first dose is not given until 4 years of age.

Administer intramuscularly into the vastus lateralis.

Answer and Explanation

The Correct Answer is B

A. Mild illnesses like nasopharyngitis (a common cold) do not typically contraindicate vaccination, so there is no need to delay immunization.

B. It is essential to evaluate for allergies to vaccine components, such as gelatin or neomycin, which could contraindicate the administration of the varicella vaccine.

C. The first dose of the varicella vaccine is recommended at 12-15 months of age, not at 4 years of age, so it is appropriate to administer it during this well-check.

D. The varicella vaccine is administered subcutaneously, not intramuscularly, so this is not the correct route for administration.

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

Explanation

A. Droplet precautions are typically used for infections transmitted through respiratory droplets, such as influenza or COVID-19. Since the symptoms described are more consistent with pyloric stenosis rather than an infectious disease, droplet precautions are not indicated.

B. The infant's symptoms are indicative of possible hypertrophic pyloric stenosis, a condition where the pylorus (the opening from the stomach to the small intestine) becomes narrowed, leading to forceful vomiting and dehydration. Surgical intervention, such as a pyloromyotomy, is often required to correct this condition.

C. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used to assess pain in infants and young children who cannot verbalize their discomfort. Given the infant's fussiness and symptoms, evaluating pain is crucial to managing the infant's discomfort.

D. Monitoring intake and output is important in an infant with vomiting to assess for dehydration and ensure appropriate fluid balance. This is a key aspect of managing any vomiting-related condition and ensuring the infant receives adequate hydration.

E. In the case of hypertrophic pyloric stenosis, thickened liquids are not recommended. The main treatment is surgical, and feeding modifications alone will not address the underlying condition.

F. A plain water enema is not appropriate for this infant’s symptoms. Hypertrophic pyloric stenosis does not require an enema and may actually worsen the infant's condition.

A. Encourage increased fluid intake. B. Administer antibiotics. C. Encourage frequent ambulation. D. Obtain weight weekly.

Correct Answer is B

Explanation

A. Fluid intake is usually restricted to prevent fluid overload, which can worsen edema and hypertension in acute glomerulonephritis.

B. Administering antibiotics may be necessary, especially if the condition is secondary to a streptococcal infection, which is a common cause of acute glomerulonephritis.

C. Rest is typically encouraged rather than frequent ambulation, as activity can exacerbate symptoms.

D. Daily weights, not weekly, are crucial for monitoring fluid balance in acute glomerulonephritis.

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During a well-check for a 12-month-old, the nurse plans to administer the first dose of the varicella vaccine. What is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is planning care for a client who has acute glomerulonephritis. Which intervention should the nurse include in the plan when caring for this client?

Correct Answer is B

Explanation

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