Nokea
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Inactivated poliovirus vaccine
- C. Tetanus toxoid
- D. Hepatitis B vaccine
Correct Answer: C
Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.
You may also like to solve these questions
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response is correct?
- A. One year
- B. Five years
- C. 10 years
- D. Life
Correct Answer: D
Rationale: Liver transplant recipients require lifelong immunosuppression to prevent graft rejection, as the immune system continuously recognizes the transplant as foreign.
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: B
Rationale: Supine position provides access to the sternum for bone marrow aspiration. Dorsal recumbent (A) is for abdominal exams, High Fowler’s (C) is for breathing, and lithotomy (D) is for pelvic procedures.
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. Providing pain relief
- C. Preventing infection
- D. O2 therapy
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
The client is prescribed levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include?
- A. Take the medication at bedtime.'
- B. Report palpitations or chest pain.'
- C. Increase dietary fiber to prevent constipation.'
- D. Take the medication with meals.'
Correct Answer: B
Rationale: Levothyroxine can cause cardiac side effects like palpitations or chest pain, which should be reported. It is taken in the morning, fiber is not directly related, and food reduces absorption.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.