Hesi for NUR 112 Exam Questions & Answers with Rationales Updated (Deeply Explained)-A 4-month-old infant is admitted to the pediatric unit. How does the primary nurse expect the infant to behave when approached?
a. S
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Hesi for NUR 112 Exam Questions & Answers with Rationales Updated (Deeply Explained)-A 4-month-old infant is admitted to the pediatric unit. How does the primary nurse expect the infant to behave when approached?
a. Smile socially in recognition of the nurse
b. Cry when the nurse approaches for the first time
c. Reach out to the nurse for the attention that is being offered
d. Cling to the mother when the nurse tries to establish contact - C!
The infant has not yet recognized boundaries between self and mother and is not particular about who meets and resolves needs. The infant is most likely reaching out for attention. A social smile does not indicate recognition of a specific person, only a human face. The infant does not yet differentiate familiar faces from those of strangers. The infant does not understand or fear separation from the mother yet.
A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine?
a. Allergy to eggs
b. Lactose intolerance
c. Infectious dermatitis
d. High fever after the first dose - D!
A temperature of 105° F (40.5° C) or higher after a DTaP immunization is a contraindication to further DTaP immunizations. An allergy to eggs is not a contraindication to the administration of the DTaP vaccine because eggs are not used in the production of the vaccine. Lactose intolerance is not a contraindication to the administration of DTaP vaccine; nor is infectious dermatitis.
A 6-month-old infant is to receive scheduled immunizations. The parents ask why two influenza vaccines are given: Haemophilus influenzae type B (Hib) and pneumococcal conjugate vaccine (PCV). How should the nurse respond?
a. PCV prevents influenza.
b. Hib is given to prevent pneumonia.
c. Hib and PCV prevent different bacterial diseases.
d. PCV and Hib are given together to protect against viral and bacterial diseases. - C!
Both vaccines protect against bacterial infections. The PCV protects against bacterial pneumonia. The Hib vaccine protects against bacterial infections caused by Haemophilus influenzae type B; these include otitis media, meningitis, epiglottitis, septic arthritis, and sepsis. The PCV conjugate vaccine protects against infections caused by the Streptococcus pneumoniae bacterium (pneumococcal pneumonia).
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A 10-year-old child who is developmentally delayed and blind must be fed all meals. The child has problems swallowing and frequently chokes and coughs during the feeding. What technique should the nurse use when feeding this child?
a. Holding the child in an upright position and using a soft-tipped bulb syringe
b. Placing the child in the supine position and turning the child's head to the right
c. Seating the child in a wheelchair, giving small bites of food with metal tableware, and encouraging participation
d. Propping the child in a semisitting position, providing chopped food, and placing it in the child's mouth with plastic tableware - C!
An upright position helps prevent aspiration; gravity facilitates movement of food down the esophagus and into the stomach. Metal tableware is safer than plastic tableware because it is unbreakable; a mentally challenged child could easily bite down on and break a plastic utensil and choke on the fragments. Encouraging participation, with socialization, and treating the child with dignity should be part of the meal. Although the child might assume an upright position, using a syringe is a form of forced feeding; in addition, the child should be encouraged to eat solid foods. Feeding in the supine position puts the child at risk for aspiration and choking. Solid, not chopped, food should be encouraged.
A 16-year-old male student who was injured while skateboarding arrives in the emergency department with a deep laceration of his leg. He does not remember when he received his last tetanus immunization. The nurse explains that tetanus immunoglobulin (TIG) and tetanus toxoid are required because:
a. Neither medication is effective alone.
b. Both eliminate the need for additional medications.
c. Different mechanisms are used to stimulate the immune response.
d. Tetanus toxoid minimizes the risks related to the tetanus immunoglobulin. - C!
TIG provides immediate protection, whereas the tetanus toxoid initiates an active immune response. Each is effective alone, but the combination is preferred. They do not confer lifelong immunity. After the initial routine immunizations and boosters, it is recommended that the tetanus toxoid be administered every 10 years. TIG does not carry major side effects because it is derived from human
A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome (AIDS). The primary nurse reports to the nursing team that the client cried when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify that this comment most likely is a result of the nursing assistant's:
a. Values and beliefs about sexual lifestyles.
b. Anger and mistrust of homosexual males in general.
c. Discomfort with men who are unable to control their emotions.
d. Hostility over having to care for someone with a sexually transmitted infection - A!
This statement reflects values and beliefs regarding homosexuality as being bad and deserving of punishment. There is not enough evidence presented to justify drawing the conclusion that the nursing assistant has anger and mistrust of homosexual males in general or discomfort with men who are unable to control their emotions. Although there may be hostility over having to care for someone with a sexually transmitted infection, no information is given to suggest that the nursing assistant has been assigned to care for this client.
A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should:
a. Give the vaccine
b. Administer aspirin with the vaccine
c. Hold the vaccine and notify the health care provider
d. Reschedule administration of the vaccine for the next month - D!
The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary.
A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included?
a. "Increase your intake of fat with each meal."
b. "Lie down after eating to help your digestion."
c. "Reduce your caloric intake to foster weight reduction."
d. "Drink several glasses of fluid during each of your meals." - C!
Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Unstageable - D!
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?
a. Maintain the head of the bed at 35 degrees or less.
b. With the help of another staff member, use a drawsheet when lifting the client in bed.
c. Reposition the client at least every 2 hours and support the client with pillows.
d. At least once every 8 hours, perform passive range-of-motion exercises of all extremities. - B!
Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows and at least once every 8 hours, and performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.
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