16.  A nurse is caring for a 6-month-old child. The child’s provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?

18. The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client’s risk factors associated with the allergy, the nurse questions the client about an allergy to which food items? Select all that apply.

33.  The nurse is planning an information session on immunity and immunizations with a group of seniors at the county senior center. The nurse recalls the following are effects on the normal aging system:  Select all that apply.

21. Review the scenario below: Which of the following actions would the nurse anticipate: Orders Labs Nurse Note IV 0.9% NACL @ 100 mL/ HR Vancomycin 500 mg/250 mL every 6 hours IVPB Rocephin 1 gram IV piggy back every 12 hours ibuprofen 400 mg by mouth every 6 hours as needed for pain Vital Signs Q 4 hours Diet as tolerated Wound care to LLE twice daily-cleanse with wound cleanse, pat dry, cover with sterile 4x4s and secure with Tegaderm.  Foley to drainage bag Strict I&O Daily Weight Ambulate with assist Up in chair TID for meals   CBC:  WBC 15,700 RBC 3.7 Hgb 11.5 HCT 37.9 PLT 268,000 neutrophils 47% Lymphs 46% Monocytes  6% EOS 1% Basos 0 % CMP: BUN 24 mg/dL Creatinine 1.5 mg/dL Na+ 132 mmol/L K+ 3.3  mmol/L Chloride 96 mmol/L Calcium 8.9 mg/dL   0610: Client resting in bed, responds to verbal stimulus, alert and oriented to time, place and situation. IV site to LEFT forearm patent, infusing NS @ 100mL/hr via pump, without redness or edema at site. Denies complaints of tenderness.  Dressing to Left lower leg dry/intact. Skin warm and dry. Extremities with 3+ cap refill, dorsalis pedis pulses palp and equal bilat.  Abdomen soft, non-tender. Bowel sounds hyperactive x 4 quads. Last BM reported by patient this morning was watery, large amount with a foul odor. Complains of abdominal cramping and nausea. Oral cavity without redness/lesions.  Foley intact, patent and draining clear, pink tinged urine. . Bladder non distended.   requests antidiarrheal at this time. Will continue to monitor. 

2.  The nurse is providing education for the parents of an infant during his 4 month well visit. She explains that the process of building immunity through a controlled exposure to an attenuated organism that will stimulate the production of antibodies is required by  _______________.

24. The nurse is caring for a patient who was admitted to the post op floor following total knee replacement surgery 3 hours ago. The physician has ordered Rocephin 1G daily. Which of the following would warrant further clarification of this order?

A 42-year-old patient with a history of alcohol use disorder has been prescribed disulfiram as part of their treatment plan. The patient reports feeling anxious about potential side effects and is considering not taking the medication. Which of the following analyses best explains the rationale behind using disulfiram in alcohol addiction treatment?

A 29-year-old nurse is admitted to the medical unit with symptoms of septic arthritis in her knee. The patient has a history of multiple hospitalizations for various infections over the past year. During assessment, the nurse notices inconsistencies in the patient’s reported symptoms and medical history. Which of the following actions should the nurse prioritize?

A nurse is developing a comprehensive care plan for a 35-year-old patient newly diagnosed with major depressive disorder and prescribed sertraline (an SSRI). The patient has a history of anxiety, works night shifts, and expresses concerns about medication side effects.  Which combination of interventions would be most appropriate for the nurse to include in the patient’s care plan?

A nurse is working with a client diagnosed with agoraphobia who is reluctant to attend group therapy in the group room down the hall. Which of the following responses by the nurse would be most appropriate and therapeutic?