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."

Answer and Explanation

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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Correct Answer is C

Explanation

Maintaining a healthy lifestyle is crucial for managing mild hypertension. One of the key lifestyle changes recommended for individuals with hypertension is reducing salt (sodium) intake.

The American Heart Association recommends limiting sodium intake to no more than 2,300 milligrams (about 2 grams) per day. By expressing the goal to decrease salt intake to 2 grams per day, the client demonstrates an understanding of the teaching.

A. Collect a sterile specimen from the urinary drainage bag B. Instruct the client to hold the drainage bag at waist height when ambulating C. Secure the tubing with adhesive/impe to the lower abdomen. D. Coil the tubing on the bed above the collection bag

Correct Answer is C

Explanation

A.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

B.Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C.Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D.Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe..

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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