Page 590 - Saunders Comprehensive Review For NCLEX-RN

1. Discourage reminiscing.
2. Make the decisions for the family.

3. Encourage expression of feelings, concerns, and fears.

4. Explain everything that is happening to all family members.

5. Touch and hold the client’s or family member’s hand if

appropriate.
6. Be honest and let the client and family know they will not be
abandoned by the nurse.
170. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP)
immunization at a well-baby clinic. The parent returns home and calls the
clinic to report that the infant has developed swelling and redness at the site
of injection. Which intervention should the nurse suggest to the parent?
1. Monitor the infant for a fever.
2. Bring the infant back to the clinic.
3. Apply a hot pack to the injection site.
4. Apply a cold pack to the injection site.
171. A child is receiving a series of the hepatitis B vaccine and arrives at the clinic
with his parent for the second dose. Before administering the vaccine, the
nurse should ask the child and parent about a history of a severe allergy to
which substance?
1. Eggs
2. Penicillin
3. Sulfonamides
4. A previous dose of hepatitis B vaccine or component
172. A parent brings her 4-month-old infant to a well-baby clinic for
immunizations. The child is up to date with the immunization schedule. The
nurse should prepare to administer which immunizations to this infant?
1. Varicella, hepatitis B vaccine (HepB)
2. Diphtheria, tetanus, acellular pertussis (DTaP); measles, mumps,
rubella (MMR); inactivated poliovirus vaccine (IPV)
3. MMR, Haemophilus influenzae type b (Hib), DTaP
4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), rotavirus vaccine
(RV)
173. The clinic nurse is assessing a child who is scheduled to receive a live virus
vaccine (immunization). What are the general contraindications associated
with receiving a live virus vaccine? Select all that apply.

1. The child has symptoms of a cold.

2. The child had a previous anaphylactic reaction to the vaccine.
3. The mother reports that the child is having intermittent

episodes of diarrhea.
4. The mother reports that the child has not had an appetite and

has been fussy.

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