Nokea
Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
- A. the child with a runny nose
- B. the child who experienced a seizure after the last immunization
- C. the child who experienced a life-threatening allergic reaction after the last immunization
- D. the child with a temperature of 102°F
Correct Answer: A
Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.
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The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?
- A. Fragile bones, blue sclera, and brittle teeth
- B. Epicanthal folds, broad hands, and transpalmar creases
- C. Low posterior hairline, webbed neck, and short stature
- D. Developmental regression and cherry-red macula
Correct Answer: B
Rationale: Down syndrome is characterized by epicanthal folds, broad hands, and transpalmar creases.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage
The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:
- A. A false elevation
- B. A false low reading
- C. A blood pressure reading that is correct
- D. A subnormal finding
Correct Answer: A
Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.
A transient homeless client with a history of mental illness and substance abuse is to be discharged. Which of the following support systems are most likely to provide social support for the client? Select all that apply.
- A. Self-help programs.
- B. Internet-based programs.
- C. Community agencies.
- D. Governmental agencies.
- E. Friends.
- F. Family.
Correct Answer: A,C,D
Rationale: Community agencies (C), governmental agencies (D), and self-help programs (A) are likely to provide social support for a homeless client with mental illness and substance abuse. Internet-based programs (B), friends (E), and family (F) may be less accessible or reliable.
The nurse is monitoring a client's cardiac rhythm when an abnormal rhythm occurs. Which of the following cardiac rhythms does the ECG strip (see image) indicate?
- A. Ventricular fibrillation
- B. Ventricular tachycardia
- C. Atrial fibrillation
- D. Atrial flutter
Correct Answer: B
Rationale: Without the ECG strip, ventricular tachycardia (B) is a common abnormal rhythm requiring urgent intervention, characterized by wide QRS complexes. Other rhythms (A, C, D) have distinct patterns.