Nokea
A healthcare professional is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old child. Which of the following findings is a contraindication to the administration of this vaccine?
- A. Family history of egg allergy
- B. Currently taking antibiotics
- C. History of asthma
- D. Presence of rhinorrhea
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
- A. Page an anesthesiologist immediately and prepare to intubate the client
- B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary
- C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client's vital signs
- D. Insert an indwelling urinary catheter and begin to infuse IV fluids as ordered
Correct Answer: B
Rationale: When a client exhibits symptoms of anaphylactic shock after receiving penicillin, the priority nursing intervention is to administer epinephrine, as prescribed, to counteract the severe allergic reaction. Epinephrine helps to improve breathing and increase blood pressure. Intubation may be necessary in severe cases to maintain airway patency. Therefore, the nurse should administer epinephrine first before considering intubation. It is crucial to act swiftly to prevent further deterioration in the client's condition.
Considering Mr. Franco's conditions, which of the following is most important to include in preparing Franco's bedside equipment?
- A. Hand bell and extra bed linen
- B. Footboard and splint
- C. Sandbag and trochanter rolls
- D. Suction machine and gloves
Correct Answer: C
Rationale: Mr. Franco's conditions indicate a need for positioning aids and support to prevent pressure ulcers and maintain proper alignment. Sandbags can be used to provide support and stability for his lower extremities, while trochanter rolls can help maintain proper alignment of his hips and prevent external rotation of the legs. These aids are crucial in ensuring Mr. Franco's comfort, safety, and overall well-being during his stay in bed.
The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurse's reply should be based on which of the following?
- A. Child is too young to digest hot dogs.
- B. Child is too young to eat hot dogs safely.
- C. Hot dogs must be sliced into sections to prevent aspiration.
- D. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A parent of an infant with gastroesophageal reflux is being taught by a nurse. Which of the following instructions should the nurse include in the teaching?
- A. Offer the infant feedings every 2 hours.
- B. Position the infant upright after feedings.
- C. Feed the infant thickened formula.
- D. Place the infant in a prone position after feedings.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which is not true concerning allergic reactions to foods?
- A. Most adverse reactions to foods do not have an immunologic basis.
- B. Rashes and diarrhea after ingestion of fruit juices usually have an immunologic basis.
- C. Positive skin test results must be confirmed by food challenge.
- D. Persons with IgE-mediated food reactions consistently have positive skin test results.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.