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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.
Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.
Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.
Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.
Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.
Correct Answer is A
Explanation
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
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