What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?

Measure the child's temperature and postpone the immunizations if the fever is over 100°F.

Administer the vaccinations as scheduled.

Give the infant the flu vaccination but withhold the others.

Postpone all vaccinations.

Answer and Explanation

The Correct Answer is A

Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.

Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.

Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.

Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.

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Correct Answer is C

Explanation

Choice A reason: Adolescents are capable of more complex thinking and are less likely to view illness as a punishment for misdeeds.

Choice B reason: Infants do not have the cognitive ability to associate illness with punishment.

Choice C reason: This is the correct choice. Preschool-age children often engage in magical thinking and may view illness as a punishment for misdeeds.

Choice D reason: School-age children are beginning to understand the biological causes of illness and are less likely to view it as a punishment.

A. Lift and clear drainage from the chest tube. B. Inspect the tube insertion site for leaking. C. Continue to monitor the drainage system. D. Auscultate lungs for unequal breath sounds.

Correct Answer is C

Explanation

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary unless there is a blockage, which is not indicated by the water level changes.
Choice B reason: Inspecting the tube insertion site for leaking is important but not related to the observation of water level changes in the water-seal chamber.
Choice C reason: This is the correct choice. The water level rising during inspiration and falling during expiration is a normal finding that indicates the chest tube is functioning properly.
Choice D reason: Auscultating lungs for unequal breath sounds is part of the assessment but does not address the observed water level changes in the water-seal chamber.

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What is the most appropriate action for the nurse to take, given that a 4-month-old infant, brought in for a routine checkup and vaccinations, was exposed to a sibling with the flu?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When developing a plan of care for a hospitalized child, the nurse knows that children in which age group are most likely to view illness as a punishment for misdeeds?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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