A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Chemotherapy treatments

Medications for a cardiac anomaly

Clear rhinorrhea

Two diarrhea stools in the last day

Answer and Explanation

The Correct Answer is A

Chemotherapy treatments, which are used to treat cancer, can suppress the immune system and weaken the body's ability to respond to vaccines. As a result, receiving a live attenuated vaccine like the varicella immunization can pose a risk of severe complications for individuals undergoing chemotherapy. Therefore, it is contraindicated to administer the varicella vaccine in this case.

Medications for a cardiac anomaly, clear rhinorrhea, and two diarrhea stools in the last day are not contraindications for receiving a varicella immunization.

While medications for a cardiac anomaly and certain medical conditions may require special consideration or precautions when administering vaccines, they are not absolute contraindications for the varicella vaccine. The decision to administer the vaccine would depend on the individual's specific circumstances and the healthcare provider's assessment. Clear rhinorrhea (runny nose) and two diarrhea stools in the last day are considered minor illnesses and do not contraindicate the varicella vaccine. Generally, mild illnesses without fever or systemic symptoms do not pose a significant risk when receiving vaccines. However, it is always important to assess the overall health status of the individual and consult with a healthcare provider if there are concerns.

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Correct Answer is B

Explanation

The nurse should describe hyperactive bowel sounds as sounds that are loud, high-pitched, and increased in frequency and intensity. They are more frequent than the normal bowel sounds, with a rapid succession of sounds occurring at a rate greater than 5 to 30 sounds per minute.

Hyperactive bowel sounds can be heard in conditions such as gastroenteritis, diarrhea, and early mechanical bowel obstruction. They indicate increased bowel motility and are often associated with increased peristalsis.

To differentiate hyperactive bowel sounds from normal or hypoactive bowel sounds, the nurse can explain that hypoactive bowel sounds are decreased or absent sounds that occur when the bowel motility is decreased, such as in conditions like paralytic ileus or after abdominal surgery. Normal bowel sounds are typically soft, low-pitched, and occur at a rate of 5 to 30 sounds per minute.

A. I need to use iodine to disinfect cuts on my feet. B. I should soak my feet in warm water every morning. C. I will wear a clean pair of cotton socks each day. D. I can remove ingrown toenails at home as needed.

Correct Answer is C

Explanation

Explanation

C. I will wear a clean pair of cotton socks each day

Wearing a clean pair of cotton socks each day is an important aspect of foot care for individuals with diabetes. Here's why the other options are incorrect:

Using iodine to disinfect cuts on the feet in (option A) is not recommended for individuals with diabetes as it can be irritating to the skin and delay wound healing. It is best to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.

Soaking feet in warm water every morning in (option B) is not recommended for individuals with diabetes. Prolonged exposure to water can increase the risk of dryness and cracking, leading to skin breakdown and infections. It is advisable to avoid prolonged soaking and to dry the feet thoroughly after washing.

Removing ingrown toenails at home in (option D) is not recommended for individuals with diabetes. Attempting to do so can result in injury and increase the risk of infection. It is important for individuals with diabetes to seek professional care for any foot-related concerns, including ingrown toenails.

In summary, the correct statement is C: "I will wear a clean pair of cotton socks each day." This demonstrates an understanding of the importance of foot hygiene and minimizing moisture to reduce the risk of fungal infections and foot complications for individuals with diabetes.

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A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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