A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.
Which instruction should the nurse provide the parent about care of the infant after the injections?

Keep the infant home from daycare for the next two days.

Apply a cool pack to the injection site to reduce discomfort.

Administer children’s aspirin to help prevent inflammation.

Any level of fever is serious and should be reported right away.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

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Correct Answer is C

Explanation

Choice A rationale

Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.

Choice B rationale

Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.

Choice C rationale

Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.

Choice D rationale

Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.

A. Prepare the patient for repeat blood cultures. B. Arrange emergency transport to an inpatient facility. C. Explain the need to evaluate liver function. D. Instruct the patient to increase protein intake.

Correct Answer is C

Explanation

Choice A rationale

While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice B rationale

Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.

Choice C rationale

Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.

Choice D rationale

While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.

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A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest.Which action should the nurse take?

Correct Answer is C

Explanation

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

Correct Answer is C

Explanation

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A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.
Which instruction should the nurse provide the parent about care of the infant after the injections?