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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. It's crucial for the client to adhere strictly to the prescribed dosage and schedule to maximize therapeutic benefits and minimize potential side effects. However, temperature regulation is priority
B. Celiac disease requires strict adherence to a gluten-free diet to prevent intestinal damage, while multiple sclerosis management may involve dietary strategies to manage symptoms like fatigue or bladder dysfunction. However, increasing sodium intake generally is not a primary concern unless there are specific indications related to multiple sclerosis symptoms or medication effects.
C. Temperature sensitivity is common in multiple sclerosis, and exposure to extreme heat or cold can exacerbate symptoms such as fatigue, weakness, and cognitive dysfunction. Managing environmental temperature exposure is crucial to minimizing symptom exacerbation and maintaining comfort and safety.
D. Mobility aids, such as walkers, can assist individuals with multiple sclerosis during periods of weakness or impaired balance. Using a walker appropriately can help prevent falls and promote safe mobility. However, this instruction may be more specific to managing symptoms of multiple sclerosis rather than addressing the complex dietary needs associated with celiac disease.
Correct Answer is B
Explanation
Rationale
A. Nausea and headache are common side effects of linezolid. While they can impact the client's comfort and adherence to treatment, they are generally not considered urgent or life-threatening unless severe or persistent.
B. Watery diarrhea is a significant concern with linezolid therapy, as it can indicate the development of Clostridium difficile infection (CDI) or other types of antibiotic-associated diarrhea. CDI is a severe condition that requires prompt treatment to prevent complications such as dehydration, colitis, and potentially life-threatening outcomes like toxic megacolon.
C. Increased fatigue can be a nonspecific symptom and may result from various factors, including the underlying illness (nosocomial pneumonia), medication side effects, or the stress of hospitalization. While it should be monitored, it is typically not an immediate concern unless accompanied by other concerning symptoms.
D. Yellow-tinged sputum can indicate the presence of infection or inflammation in the respiratory tract, which is relevant in the context of nosocomial pneumonia. It could suggest a worsening of the pneumonia or a new infection. However, it is not typically directly associated with linezolid therapy itself.
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