A nurse is preparing to administer tetanus and diphtheria toxoids (Td) to a client. What technique the nurse should plan to use?

Answer and Explanation

The Correct Answer is ["intramuscular injection technique"]

The Td vaccine is typically administered into the muscle, most commonly in the deltoid muscle of the upper arm for adults. The IM injection technique involves inserting the needle into the muscle and injecting the vaccine into the muscle tissue.

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Correct Answer is A

Explanation

Monitoring the infant's lymphocyte count is important in evaluating the immune function of the infant. HIV primarily affects the immune system, including lymphocytes. Monitoring the lymphocyte count helps assess the progression of the disease and the effectiveness of treatment.

Exchange transfusions are not typically used in the management of HIV. They are primarily performed in conditions like severe neonatal jaundice or blood disorders, but not for the treatment of HIV.

Granulocyte colony-stimulating factor (G-CSF) is a medication used to stimulate the production of white blood cells called granulocytes. While G-CSF can be used in certain situations, such as to counteract the side effects of certain chemotherapy drugs, it is not a standard treatment for HIV in infants.

Droplet precautions are typically implemented for infectious diseases that spread through respiratory droplets, such as influenza or respiratory syncytial virus (RSV). HIV does not spread through respiratory droplets, so initiating droplet precautions would not be necessary in the care of an infant with HIV.

A. A client who is postoperative and reports intermittent nausea B. A client whose blood pressure is 160/90 mm Hg and reports a headache C. A client who is scheduled for surgery in 2 hr D. A client who is postoperative and has a Jackson-Pratt drain

Correct Answer is B

Explanation

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

The client who is postoperative and has a Jackson-Pratt drain should be assessed and managed, but their condition does not require immediate intervention compared to the client with the elevated blood pressure and headache.

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A nurse is preparing to administer tetanus and diphtheria toxoids (Td) to a client. What technique the nurse should plan to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?

Correct Answer is B

Explanation

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