A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

Haemophilus influenzae type b (Hib)

Varicella (VAR)

Hepatitis B (HepB)

Meningococcal (MCV4)

Answer and Explanation

The Correct Answer is B

Choice A reason: Haemophilus influenzae type b (Hib) vaccine is not the correct choice, as it is usually given to children at 2, 4, 6, and 12 to 15 months of age. A 4-year-old child should have already completed the Hib vaccine series.

Choice B reason: Varicella (VAR) vaccine is the correct choice, as it is recommended for children at 12 to 15 months and 4 to 6 years of age. A 4-year-old child is due for the second dose of the VAR vaccine.

Choice C reason: Hepatitis B (HepB) vaccine is not the correct choice, as it is usually given to children at birth, 1 to 2 months, and 6 to 18 months of age. A 4-year-old child should have already completed the HepB vaccine series.

Choice D reason: Meningococcal (MCV4) vaccine is not the correct choice, as it is not routinely recommended for children younger than 11 years of age. MCV4 vaccine is given to children at 11 to 12 years and 16 years of age, or to children with certain high-risk conditions.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Balancing the scale to 0 prior to use is a correct action for the nurse to take. This ensures that the scale is accurate and does not include any extra weight from the scale itself or any objects on it.

Choice B reason: Using a stadiometer to measure the infant is not a correct action for the nurse to take. A stadiometer is a device that measures the height of a standing person. It is not suitable for measuring the length of an infant who cannot stand. The nurse should use a measuring board or a tape measure to measure the infant's length.

Choice C reason: Placing a disposable covering on the scale is a correct action for the nurse to take. This prevents the transmission of germs or dirt from the scale to the infant or vice versa. It also protects the scale from any urine or stool that the infant may produce during the weighing.

Choice D reason: Weighing the infant in a diaper is not a correct action for the nurse to take. A diaper can add extra weight to the infant's measurement and affect the accuracy of the result. The nurse should weigh the infant without any clothing or diaper.

Choice E reason: Measuring the infant from crown of the head to the heels of feet is a correct action for the nurse to take. This is the standard method of measuring the length of an infant. The nurse should place the infant on a flat surface, align the head with the top of the measuring board or tape measure, and extend the legs fully. The nurse should then read the measurement at the bottom of the infant's feet.

A. Tetany B. Slow, bounding pulse C. Decreased temperature D. Irritability

Correct Answer is D

Explanation

Choice A reason: Tetany is not a typical finding in an infant who is dehydrated. Tetany is a condition where the muscles contract involuntarily and cause spasms or cramps. It is usually caused by low calcium levels or alkalosis, not dehydration.

Choice B reason: Slow, bounding pulse is not a typical finding in an infant who is dehydrated. A slow, bounding pulse may indicate increased intracranial pressure or heart failure, not dehydration. A fast, weak pulse is more likely to occur in an infant who is dehydrated.

Choice C reason: Decreased temperature is not a typical finding in an infant who is dehydrated. A decreased temperature may indicate hypothermia or sepsis, not dehydration. A normal or slightly elevated temperature is more likely to occur in an infant who is dehydrated.

Choice D reason: Irritability is a typical finding in an infant who is dehydrated. Irritability indicates that the infant is uncomfortable and thirsty. It may also be a sign of cerebral dehydration, which can affect the infant's mental status and behavior.

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A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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