Nokea
A client with a fractured right femur has not had any immunizations since childhood. Which of the following biological products should the nurse administer to provide the client with passive immunity for tetanus?
- A. Tetanus toxoid.
- B. Tetanus antigen.
- C. Tetanus vaccine.
- D. Tetanus antitoxin.
Correct Answer: D
Rationale: Tetanus antitoxin provides passive immunity, neutralizing existing toxin in unvaccinated clients.
You may also like to solve these questions
Which of the following indicates a potential complication of diabetes mellitus?
- A. Inflamed, painful joints.
- B. Blood pressure of 160/100 mm Hg.
- C. Hemoglobin of 11 g/dL.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: B
Rationale: Hypertension (160/100 mm Hg) is a common complication of diabetes, contributing to cardiovascular and kidney disease.
A 10-year-old client is diagnosed with infectious mononucleosis. Her white blood cell (WBC) count is 19,000/µL. She has a streptococcal throat infection and her spleen is enlarged. She has aching muscles. Which of the following instructions should the nurse include in discharge planning with the client and the essential caregiver? Select all that apply.
- A. Stay on bed rest until the temperature is normal.
- B. Gargle with warm saline while the throat is irritated.
- C. Increase intake of fluids until the infection subsides.
- D. Take aspirin as long as the fever and myalgia persist.
- E. Avoid contact sports while the spleen is enlarged.
Correct Answer: B,C,E
Rationale: Infectious mononucleosis with an enlarged spleen requires avoiding contact sports to prevent splenic rupture, a serious complication. Gargling with warm saline soothes the throat, and increased fluids support recovery and prevent dehydration. Bed rest is not strictly necessary unless fever persists, and aspirin should be avoided in children due to the risk of Reye's syndrome.
The nurse is assessing a client receiving intravenous (IV) fluids via a peripheral vascular access device (PVAD). Assessment findings show swelling and tenderness at the infusion site. The nurse should perform which action?
- A. stop the infusion and remove the PVAD
- B. remove the dressing and reposition the PVAD
- C. instruct the client to perform range of motion activities in the affected arm
- D. place the arm in a dependent position
Correct Answer: A
Rationale: Swelling and tenderness indicate infiltration, requiring stopping the infusion and removing the PVAD.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such as fever, chills, and fatigue, which are expected adverse effects. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typically associated with this medication.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage?
- A. Numbness.
- B. Bleeding.
- C. Dislocation.
- D. Pinkness.
Correct Answer: A
Rationale: Numbness indicates potential nerve damage, requiring urgent evaluation.