A parent asks 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?
Chewable children's aspirin will help prevent inflammation.
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.
The Correct Answer is D
Choice A reason: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.
Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.
Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.
Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: c. Inspiratory and expiratory bilateral crackles.
Choice A: Average urine output of 28 mL/hour
Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.
Choice B: Vesicular bibasilar breath sounds
Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.
Choice C: Inspiratory and expiratory bilateral crackles
Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.
Choice D: Central venous pressure of 12 mm Hg
Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.
Correct Answer is B
Explanation
Choice A reason: Telling the charge nurse and refusing to administer the placebo could be seen as insubordination and does not address the ethical concerns associated with placebo use.
Choice B reason: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.
Choice C reason: Administering the placebo as prescribed without addressing the ethical implications could compromise the nurse's professional integrity and the patient's trust.
Choice D reason: Informing the client that a placebo was prescribed could undermine the treatment plan and the provider-patient relationship, potentially causing harm to the client.

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