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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A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?
- A. I know it must be terrible to see your child like this, but your child will be fine within a few days.
- B. It is important to understand that most people have permanent adverse effects after an episode like this.
- C. We cannot predict whether your child will develop schizophrenia; close observation is required to determine the cause of psychosis.
- D. Your child would be fine right now if they had not taken these drugs. We will need to do some additional testing
Correct Answer: C
Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.
The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?
- A. I will need to get my blood drawn to see if I'm taking the right dose.
- B. I will probably need to take this the rest of my life.
- C. I will take this once a day in the morning.
- D. If this makes my stomach upset, I will take it with an antacid.
Correct Answer: D
Rationale: Antacids reduce levothyroxine absorption, requiring further teaching. Blood monitoring , lifelong use , and morning dosing are correct.
The nurse is reinforcing teaching about breastfeeding to a postpartum client. Which statement by the client indicates a correct understanding of teaching?
- A. I will feed my baby for 5-10 minutes on each breast.
- B. I will hold my baby on their back with the head turned toward my breast.
- C. If I need to reposition my baby's latch, I will use my finger to break the suction first.
- D. The baby's mouth should grasp only the nipple, not the areola.
Correct Answer: C
Rationale: Breaking suction with a finger prevents nipple trauma. Short feeding times , lying on back , and nipple-only latch are incorrect.
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
- A. Promote healing and strengthen the immune system
- B. Provide a well balanced nutritional intake
- C. Stimulate increased peristalsis absorption
- D. Spare protein catabolism to meet metabolic needs
Correct Answer: D
Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.