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?

Administer children's aspirin to help prevent inflammation.

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

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

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

Answer and Explanation

The Correct Answer is D

Rationale

A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.

B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.

C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.

D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Administer a stool softener: Opioids commonly cause constipation by slowing down bowel motility and increasing water absorption in the intestines. A stool softener can help by adding moisture to the stool, making it easier to pass.

Ask the client about their normal bowel routine: Understanding the client's typical bowel habits can provide insights into any deviations caused by the surgery or medication.

Parameters to monitor

Fluid intake: Monitoring the client's fluid intake is crucial as adequate hydration helps maintain bowel function and prevents constipation.

Serum potassium level: Constipation, especially if severe or prolonged, can lead to electrolyte imbalances such as hypokalemia (low potassium levels), which can have serious health implications.

A. Aspirin. B. Nitroglycerin. C. Morphine. D. Heparin.

Correct Answer is B

Explanation

Rationale

A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin

B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.

C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.

D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.

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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

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Parameters to monitor

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Correct Answer is B

Explanation

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?