A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunizations. Which of the following statements by a guardian indicates an understanding of the teaching?
"I should not feed my baby anything for 2 hours prior to an immunization."
"I should expect my baby to have a high fever for 24 hours after an immunization."
"My baby will receive the rotavirus immunization orally
"My baby will receive three doses of the meningococcal immunization before kindergarten."
The Correct Answer is C
The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.
There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.
While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.
The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.
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Related Questions
Correct Answer is C
Explanation
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
Correct Answer is D
Explanation
Understanding the literacy level of the older adults is crucial for developing an effective education program. It helps the nurse tailor the content, language, and teaching methods to ensure that the material is accessible and understandable to the participants. By assessing their literacy level, the nurse can identify any potential barriers to learning and make appropriate adjustments to promote effective communication and comprehension.
Once the literacy level is determined, the nurse can then proceed with the other actions, such as establishing learning outcomes, scheduling a time to implement the program, and creating handouts that are suitable for the participants' literacy level. However, determining the literacy level should be the first step in order to create an inclusive and effective educational experience for the older adults.
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