Nokea
The nurse employed in a well-baby clinic is preparing to administer the scheduled recommended immunizations to a 2-month-old infant. After consultation with the pediatrician, the nurse should prepare to administer which vaccines at this time?
- A. Rotavirus (RV)
- B. Pneumococcal (PCV)
- C. Inactivated poliovirus (IPV)
- D. Varicella; measles, mumps, and rubella (MMR)
- E. Haemophilus influenzae type b conjugate (Hib)
- F. Diphtheria and tetanus toxoids and acellular pertussis (DTaP)
Correct Answer: A,B,C,E,F
Rationale: RV is administered at 2 months of age. PCV is administered at 2, 4, and 6 months of age and then between 12 and 15 months. IPV is administered at ages 2 and 4 months and then at age 4 to 6 years. Hib is administered at ages 2 and 4 months with a final dose administered at age 12 months or older. DTaP is administered at 2, 4, and 6 months of age; the fourth dose is administered as early as age 12 months as long as 6 months have elapsed since the third dose. Varicella vaccine is administered at age 12 months or older. MMR is administered at age 12 to 18 months with the second dose at age 4 to 6 years.
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A client has been experiencing muscle weakness for a period of several months. The health care provider suspects polymyositis, and the client asks the nurse about the disorder. The nurse explains to the client that which occurs in this disorder?
- A. Increased fibers and tissue
- B. Muscle fibers are inflamed.
- C. Muscle fibers are thickened.
- D. A decrease in elastic tissue
Correct Answer: B
Rationale: Polymyositis is a diffuse inflammatory disorder of skeletal (striated) muscle that is characterized by symmetrical weakness and atrophy. Increased fibrous tissue is seen in clients diagnosed with ankylosis. Thickened muscle fibers describe the opposite of what is noted with this disorder. Decreased elastic tissue, if it occurred in the aorta, would be noted in a client with Marfan's syndrome.
The nurse is teaching a new mother about postpartum fatigue (PPF). Which information would the nurse include?
- A. PPF is more common in women with cesarean births.
- B. Fatigue usually improves over the first 6 weeks after birth.
- C. Fatigue can help reduce the incidence of postpartum depression.
- D. Nursing mothers can minimize fatigue by breastfeeding in the side-lying position.
Correct Answer: B,D
Rationale: Fatigue improves over 6 weeks, and side-lying breastfeeding conserves energy. Cesarean births don't inherently increase PPF, and fatigue may worsen depression.
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs?
- A. Numbness and tingling are felt in the fingers.
- B. The cast feels heavy and damp after 24 hours of application.
- C. The entire cast feels warm during the first 24 hours after application.
- D. Slightly bloody drainage is noted on the cast during the first 6 hours after application.
Correct Answer: A
Rationale: A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs/symptoms of increased pressure from the cast include numbness, tingling, and increased pain. A cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.
The nurse has given the client with a nephrostomy tube instructions to follow after hospital discharge to prevent complications. The nurse determines that the client understands the instructions if the client verbalizes the need to drink how many glasses of water per day?
- A. 1 to 3
- B. 6 to 8
- C. 10 to 12
- D. 14 to 16
Correct Answer: B
Rationale: The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and provide good mechanical flushing of the kidney and the tube. The nurse encourages the client to take in 2000mL of fluid per day, which is roughly equivalent to 6 to 8 glasses of water. One to three glasses of water is an inadequate amount. Amounts over 10 glasses of water could distend the renal pelvis.
A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms?
- A. Inhaling too slowly
- B. Exhaling too slowly
- C. Not resting adequately between breaths
- D. Not forming a tight seal around the mouthpiece
Correct Answer: C
Rationale: Hyperventilation, caused by not resting adequately between breaths, is the most common cause of respiratory alkalosis, leading to lightheadedness and dizziness during incentive spirometer use. Inhaling or exhaling too slowly or not forming a tight seal may reduce effectiveness but does not cause these symptoms.