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 D

Explanation

A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.

B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.

C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.

D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.

A. Encourage the client to drink 3,000 mL of ﬂuid daily. B. Change the indwelling urinary catheter tubing every 3 days. C. Place the drainage bag on the bed when transporting the client. D. Empty the drainage bag when it is half-full. E. Review the need for the indwelling urinary catheter daily. F. Use soap and water to provide perineal care.

Correct Answer is ["A","D","E","F"]

Explanation

To decrease the risks of a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of ﬂuid daily to help ﬂush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.

Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.

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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 in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

Correct Answer is D

Explanation

Correct Answer is ["A","D","E","F"]

Explanation

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