A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
New onset of seizure disorder in the child's sibling
Evidence of sensitivity to egg antigens
Afebrile otitis media
Temperature of 40.5° C (104.9° F) after last DTaP
The Correct Answer is D
A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.
B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.
C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.
D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Keep the client's leg in a dependent position. Keeping the leg in a dependent position can increase swelling and delay healing. The leg should be elevated to reduce swelling and promote circulation.
B. Use a hair dryer on a hot setting to dry the cast. Using a hair dryer on a hot setting can cause burns and does not effectively dry a plaster cast. Plaster casts take time to dry and should be air-dried naturally.
C. Discourage the client from ambulating: Early mobilization is encouraged to prevent complications like muscle atrophy and joint stiffness, as long as it is safe and the healthcare provider has approved it. Completely discouraging ambulation is not generally recommended unless specified by a doctor.
D. Perform a neurovascular check of the lower extremities. Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast. This includes checking for pain, pallor, pulse, paresthesia, and paralysis (the 5 P’s). This helps detect complications like compartment syndrome or decreased circulation early.
Correct Answer is A
Explanation
A. Drink eight glasses of fluid daily: Maintaining hydration is crucial in preventing sickle cell crises as it helps to keep the blood less viscous, reducing the risk of vaso-occlusion.
B. Maintain an updated haemophilus influenza type B immunization: While staying up to date on vaccinations is important, it is not specific to preventing sickle cell crises.
C. Assume postural drainage positions every 6 hr: This is more relevant for respiratory conditions like cystic fibrosis, not sickle cell anemia.
D. Avoid playground activities at school: Regular activity is beneficial, but avoiding extreme physical exertion is more relevant. Normal playground activities can usually be continued with proper hydration and caution.
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