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Questions 149

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Question 1 of 5

Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?

Correct Answer: A

Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.

Question 2 of 5

A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?

Correct Answer: A

Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.

Question 3 of 5

A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first

Correct Answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.

Question 4 of 5

A student nurse overhears her instructor using the term pink puffer. The student knows this term refers to a client with which condition?

Correct Answer: C

Rationale: Pink puffer' describes emphysema patients, who maintain oxygenation (pink) but hyperventilate (puffer) due to alveolar destruction.

Question 5 of 5

The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?

Correct Answer: A

Rationale: Bananas can cause a cross-reaction in latex-allergic clients due to shared proteins (latex-fruit syndrome). Other items are safe.

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