A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine.
Which instruction should the nurse provide?
Any level of fever is serious and should be reported right away.
Keep the child home from daycare for the next two days.
Apply a cool pack to the injection site to reduce discomfort.
Chewable children’s aspirin will help prevent inflammation.
The Correct Answer is C
Choice A rationale:
While it’s important to monitor for any adverse reactions following a vaccination, not all fevers are serious. Mild fever can be a common side effect of vaccinations and is usually not a cause for concern. However, if the child develops a high fever, or if the fever is accompanied by other severe symptoms such as difficulty breathing or extreme lethargy, it should be reported to a healthcare provider immediately.
Choice B rationale:
There is no need to keep the child home from daycare following the Hib vaccine unless the child is feeling unwell or has other symptoms that warrant staying home. The Hib vaccine is not a live vaccine, so the child cannot transmit the vaccine strain to others.
Choice C rationale:
Applying a cool pack to the injection site can help reduce discomfort or swelling that may occur after the vaccination. This is a safe and effective method for managing minor side effects of vaccinations.
Choice D rationale:
Aspirin should not be given to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used to help manage any pain or fever following the vaccination, if approved by a healthcare provider. Always follow the dosing instructions on the package and consult with a healthcare provider if unsure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
4012 mg/day is not the correct answer. To calculate the maximum safe dosage of valproic acid, you need to convert the client's weight from pounds to kilograms. The client's weight in kilograms can be calculated by dividing the weight in pounds by 2.2. Therefore, 176 pounds divided by 2.2 equals 80 kilograms. The maximum safe dosage is 60 mg/kg/day, so 60 mg multiplied by 80 kg equals 4800 mg/day.
Choice B rationale:
Step 1: Convert the client’s weight from pounds to kilograms. We know that 1 kg is approximately equal to 2.2 pounds. So, we have:
176 pounds ÷ 2.2 = 80 kg (approximately)
Step 2: Calculate the maximum safe dosage for the client. We know that the maximum safe dosage of valproic acid is 60 mg/kg/day. So, we have:
60 mg/kg/day × 80 kg = 4800 mg/day
So, the maximum safe dosage for a client who weighs 176 pounds is4800 mg/day.
Choice C rationale:
3520 mg/day is not the correct answer. It does not accurately calculate the maximum safe dosage based on the client's weight.
Choice D rationale:
6171 mg/day is not the correct answer. It is significantly higher than the correct calculation and would exceed the maximum safe dosage for the client's weight.
Correct Answer is A
Explanation
Choice B rationale:
Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.
Choice C rationale:
Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.
Choice D rationale:
Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.
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