Nokea
A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
- A. New onset of seizure disorder in the child's sibling
- B. Evidence of sensitivity to egg antigens
- C. Afebrile otitis media
- D. Temperature of 40.5° C (104.9° F) after last DTaP
Correct Answer: D
Rationale: A high fever following a previous dose of DTaP may indicate a severe reaction.
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A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints to the infant?
- A. Wrist
- B. Mummy
- C. Elbow
- D. Jacket
Correct Answer: C
Rationale: Elbow restraints prevent the infant from bending their arms keeping them from touching their face and disrupting the surgical site.
Medical History
Nurses Notes
Infant has been feeding poorly and has had difficulty gaining weight. Admitted for feeding support and management.
Infant has Tetralogy of Fallot.
A nurse is assisting in the care of an infant who has congenital heart disease.
- A. Place the infant in a knee-chest position.
- B. Administer morphine via IV bolus.
- C. Provide 100% oxygen by face mask.
- D. Request a prescription for a diuretic.
- E. Perform nasopharyngeal suctioning for a maximum of 5 seconds.
- F. Prepare to assist with the insertion of a chest tube.
Correct Answer: A,B,C
Rationale: The knee-chest position morphine and oxygen are indicated for managing tet spells in Tetralogy of Fallot to improve oxygenation and reduce symptoms.
Medical History
Nurses notes:
Vital Signs:
Laboratory results:
0900:
Temperature 36.8° C (98.2° F)
Heart rate 80/min
Respiratory rate 22/min
Blood pressure 102/78 mm Hg
SaO2 is 94% on room air
Upon review of the child's electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions? Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Increased seizure activity pneumonia liver failure Steven-johnson syndrome pneumothorax due to phenytoin level cough skin rash liver enzymes lung sounds.
- A. Increased seizure activity
- B. pneumonia
- C. liver failure
- D. Steven-johnson syndrome
- E. pneumothorax
Correct Answer: A
Rationale: The child's phenytoin level is 6 mcg/mL which is below the therapeutic range of 10-20 mcg/Ml, increasing the risk of more seizures.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.
A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
- A. He takes his medication between meals with water.
- B. He only sleeps about 5 hours each night.
- C. He seems to be getting a lot more bumps and bruises lately.
- D. He has not been eating as much lately.
Correct Answer: C
Rationale: Increased bruising can indicate thrombocytopeniaa potential side effect of carbamazepine which can lead to serious bleeding issues.