Nokea
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?
- A. pneumococcal vaccine
- B. hepatitis A vaccine
- C. Lyme disease vaccine
- D. typhoid vaccine
Correct Answer: A
Rationale: Children with HIV are at higher risk for pneumococcal infections, so the pneumococcal vaccine is recommended in addition to routine vaccines. The other vaccines are not indicated for this context.
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Which of the following strategies should the nurse include when planning care for children of migrant workers?
- A. Delay immunization because of acute illness
- B. Provide parents with copies of medical records
- C. Schedule preventive services at acute illness visits
- D. Stress the importance of using one primary care provider
Correct Answer: B
Rationale: Providing medical records ensures continuity of care for migrant children, who frequently relocate, supporting consistent health management.
The nurse uses prioritization to determine all the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct Answer: C
Rationale: Treatment procedures are standards of care as defined by the facility or nursing unit. If a treatment is indicated, the nurse is obligated to follow the established procedure to be compliant with practice standards. Established priorities contribute to the determination of time management, appropriate interventions, and the need for client education as a potential intervention.
Which of the following tasks are appropriate for an LPN to perform?
- A. Adjust the cervical traction device of a 68-year-old client as instructed by the charge nurse.
- B. Teaching a 24-year-old first-time mother how to properly care for her new baby.
- C. Assess a 36-year-old man newly admitted for chest pain.
- D. Obtain an occult blood sample from a 16-year-old client with ulcerative colitis.
- E. Document the administration of acetaminophen to a 43-year-old, status post-op knee arthroplasty.
Correct Answer: A
Rationale: While LPNs are expected to perform assessments, initial assessments should always be performed by a registered nurse or attending physician. LPNs should take orders for client care and equipment adjustment from prescribing providers directly, not the charge nurse. Teaching, obtaining stool samples, and documenting medication administration are all within the scope of practice of an LPN.
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
- A. I will have a psychiatrist confirm that the news will cause negative effects, and if so, I will comply with your request.'
- B. For ethical reasons, I am unable to withhold this information from the client.'
- C. You will need to sign paperwork stating you are accepting the risk of not sharing this with the client.'
- D. You must have a durable power of attorney for health care advanced directive in place before I can consider this request.'
Correct Answer: B
Rationale: The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
There are many types of torts that can be committed against clients. They include all of the following except:
- A. Assault
- B. Battery
- C. Negligence
- D. Felony
Correct Answer: D
Rationale: Felonies are criminal acts, not torts. Torts against clients include assault, battery, negligence, slander, invasion of privacy, false imprisonment, and fraud.