The primary care NP sees a 5-year-old child for a prekindergarten physical examination
The child's parents do not have immunization records, and a local record search does not provide proof of vaccinations, although the parent thinks the child may have had some vaccines several years ago. The NP's initial action will be to: a. perform serologic tests for measles, rubella, and tetanus antigens.
b. administer TdaP, MMR, Varivax, PCV13, hepatitis A, hepatitis B, and IPV vaccines.
c. administer DTaP, Hib, hepatitis A, hepatitis B, MMR, Varivax, IPV, RV, and PCV13 vaccines.
d. ask the parent to look for immunization records and schedule an appointment for vaccines when those are found.
B
Persons without documentation of vaccine receipt should be considered nonimmunized if a reasonable effort to locate records is unsuccessful and should be started on age-appropriate vaccines. The Hib and rotavirus vaccines are not given after age 5, or 60 months of age. Serologic testing for immunity may be done for certain antigens, but this does not include tetanus.
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When the nurse is planning interventions for the patient, it is important to work with the family and patient so that they can all agree on setting:
a. actions. b. participation. c. goals. d. achievements.
A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient's right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions?
1. Internal hemorrhage 2. Fluid loss during surgery 3. Vasodilation from drugs administered during surgery 4. Left heart failure 5. Cardiac tamponade
A nursing student asks the clinic nurse why it is important to find out whether a woman in a violent relationship feels safe leaving the clinic. The best response by the nurse would be to tell the student that
a. femicide is a major cause of death, especially in African American women. b. if the woman is not safe, the nurse can have the police escort her. c. the law requires asking about patient safety in this situation. d. women who are not safe need to be given referral information.
Select the instructions by the nurse to a postoperative client who had a transsphenoidal hypophysectomy that best promote his recovery
a. If you have any ringing in your ears, let me know right away. b. Please keep your head flat for the first 12 hours after surgery. c. Do not blow your nose, cough, or sneeze for the first 48 hours after surgery. d. You must increase your fluid intake to 2 liters of fluid per day.