Nokea
Which contraindication should the nurse assess for prior to giving a child immunizations?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct Answer: C
Rationale: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.
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The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?
- A. Use medications to lower the temperature set point
- B. Apply extra layers of clothing to prevent shivering
- C. Immerse the child in a tub containing cool water
- D. Give a tepid sponge bath prior to giving an antipyretic
Correct Answer: A
Rationale: Use medications to lower the temperature set point. Antipyretics effectively reduce fever by adjusting the hypothalamic set point, preventing complications like seizures.
An eight-year-old receiving chemotherapy for six months.
Which of the following responses by the nurse is BEST?
- A. Are you afraid of dying?'
- B. Why do you ask that question?'
- C. Only God knows that answer.'
- D. We won't leave you alone.'
Correct Answer: A
Rationale: Strategy: Remember therapeutic communication. (1) correct-encourages ventilation of thoughts and feelings regarding the concern (2) inappropriate (3) ignores the child's concern with dying (4) ignores the child's concern with dying
An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
- A. Obtain an ECG
- B. Check blood gasses
- C. Dress wounds
- D. Check electrolytes
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.
An adult is admitted to the nursing care unit. He begs the nurse to give him a laxative. Which data in the admission assessment contraindicates administration of a laxative?
- A. The client has not had a bowel movement for two days.
- B. The client has a temperature of 100.8°F.
- C. The client is nauseated and vomited before admission.
- D. The client has right lower quadrant abdominal pain.
Correct Answer: D
Rationale: Right lower quadrant pain may indicate appendicitis or other acute conditions; laxatives could worsen the condition, risking perforation. Two days without a bowel movement, mild fever, or nausea do not contraindicate laxatives.