Nokea
A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine?
- A. Photophobia and hives might occur.
- B. There are no documented reactions to an MMR.
- C. Fever and hypersensitivity reaction might occur.
- D. Hypothermia might occur.
Correct Answer: C
Rationale: MMR vaccination may cause fever and hypersensitivity reactions. Photophobia, hives, and hypothermia are not typical, and reactions are well-documented.
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The nurse is caring for a patient with secondary syphilis. What intervention should the nurse institute when caring for this patient?
- A. Ensure that the patient is housed in a private room.
- B. Administer hydrocortisone ointment to the lesions as ordered.
- C. Administer combination therapy with antiretrovirals as ordered.
- D. Wear gloves if contact with lesions is possible.
Correct Answer: D
Rationale: Secondary syphilis lesions are highly infectious, requiring gloves for contact. Private rooms, hydrocortisone, and antiretrovirals are not indicated.
An older adult patient has been diagnosed with Legionella infection. When planning this patients care, the nurse should prioritize which of the following nursing actions?
- A. Monitoring for evidence of skin breakdown
- B. Emotional support and promotion of coping
- C. Assessment for signs of internal hemorrhage
- D. Vigilant monitoring of respiratory status
Correct Answer: D
Rationale: Legionella primarily affects the lungs, causing cough, dyspnea, and chest pain, so respiratory monitoring is critical. Skin breakdown, hemorrhage, and emotional support are secondary.
An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family?
- A. Family members should avoid receiving vaccinations until the patient has recovered from his or her illness.
- B. Wipe down hard surfaces with a dilute bleach solution once per day.
- C. Maintain cleanliness in the home, but recognize that the home does not need to be sterile.
- D. Avoid physical contact with the patient unless absolutely necessary.
Correct Answer: C
Rationale: A clean but non-sterile home environment is sufficient for immunosuppressed patients, as intrinsic bacteria pose greater risks than environmental ones. Avoiding vaccinations or contact is unnecessary, and daily bleach cleaning is excessive.
A patient is admitted from the ED diagnosed with Neisseria meningitidis. What type of isolation precautions should the nurse institute?
- A. Contact precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Observation precautions
Correct Answer: B
Rationale: Neisseria meningitidis spreads via large respiratory droplets, requiring droplet precautions. Airborne precautions are for smaller droplets, and observation precautions do not exist.
A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease?
- A. Standard precautions only
- B. Droplet precautions
- C. Standard and contact precautions
- D. Standard and airborne precautions
Correct Answer: D
Rationale: Pulmonary TB requires airborne precautions with standard precautions to prevent droplet transmission. Droplet or contact precautions alone are insufficient.