Nokea
The nurse is preparing to administer scheduled vaccines to a 15-month-old client with Kawasaki disease. The client received IV immunoglobulin 2 months ago. Which of the following vaccines should be delayed? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis B
- C. Measles, mumps, and rubella
- D. Pneumococcal conjugate
- E. Varicella
Correct Answer: C,E
Rationale: MMR and varicella are live vaccines, which should be delayed 11 months post-IVIG due to antibody interference. Hib , hepatitis B , and pneumococcal are not affected.
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The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
- A. Observe the child's behavior on at least 2 occasions
- B. Consult with the teacher about how to control impulsivity
- C. Compile a history of behavior patterns and developmental accomplishments
- D. Compare the child's behavior with classic signs and symptoms
Correct Answer: C
Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.
The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.
The nurse is caring for a client with chronic kidney disease who is scheduled to receive recombinant human erythropoietin and iron sucrose. Which of the following actions should the nurse take?
- A. Administer erythropoietin in the client's ventrogluteal muscle.
- B. Check the client's blood pressure prior to administering erythropoietin.
- C. Contact the health care provider to clarify the prescription for iron sucrose.
- D. Hold erythropoietin and inform the health care provider of the laboratory test results.
Correct Answer: B
Rationale: Erythropoietin can increase blood pressure, so checking BP is essential. It's given IV or SC, not IM . Iron sucrose is standard , and holding erythropoietin requires lab evidence.
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.