A nurse is preparing to administer a measles, mumps, and rubella (MMR) immunization. Which of the following client characteristics is a contraindication to administration?

Rationale:

A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.

B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.

C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.

D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.

A.Provide the caregiver with information on behavior therapy: Behavior therapy is a first-line, evidence-based nonpharmacologic intervention for ADHD, particularly in children. Educating caregivers about behavioral strategies helps improve symptom management and supports long-term success.
B. Screen the child for depression prior to initiating the medication: Although screening for comorbid conditions like depression is important in ADHD management, it is typically part of the initial diagnostic workup, which was already completed with neurology and developmental evaluations.
C. Monitor liver function test results while the child is taking the medication: Atomoxetine carries a risk of rare but serious liver toxicity. Regular monitoring of liver function is essential during treatment, especially if the child shows signs of liver dysfunction (e.g., dark urine, abdominal pain, jaundice).
D. Monitor the child for nightmares while taking the medication: Sleep disturbances, including insomnia and nightmares, are known side effects of atomoxetine. Nurses should monitor and educate caregivers about possible changes in sleep behavior while the child is on this medication.
E.Monitor the child's blood pressure at each visit: Atomoxetine can cause increases in blood pressure and heart rate. Routine monitoring of vital signs at follow-up visits is necessary to ensure cardiovascular safety during treatment.