a nurse is preparing to administer a vaccine to a child who has hemophilia which of the following actions should the nurse take

ATI RN

RN Pediatric Nursing 2023 ATI

1. A healthcare professional is preparing to administer a vaccine to a child who has hemophilia. Which of the following actions should the healthcare professional take?

A. Administer the vaccine subcutaneously
B. Administer the vaccine intramuscularly
C. Use a 1-inch needle
D. Apply pressure to the site for 1 to 2 minutes

Correct answer: B

Rationale: Administering the vaccine intramuscularly to a child with hemophilia is preferred to reduce the risk of bleeding. Hemophiliac individuals have a decreased ability to form blood clots, and administering vaccines intramuscularly reduces the risk of bleeding compared to subcutaneous administration. Using an appropriate needle length and applying pressure to the site post-injection are important steps, but choosing the intramuscular route is crucial in this case to minimize bleeding complications.

2. What is the recommended sleep duration for 14-17-year-olds?

A. 14-17 hours
B. 8-10 hours
C. 12-15 hours
D. 9-11 hours

Correct answer: B

Rationale: The recommended sleep duration for adolescents aged 14-17 is 8-10 hours to promote optimal health. Getting enough sleep is crucial for their physical and mental well-being, as it supports growth, development, learning, and overall health.

3. Which statement is not part of the developmental care approach?

A. Family-centered care
B. Care on a sliding payment scale
C. Healing environment
D. Protected sleep

Correct answer: B

Rationale: The developmental care approach emphasizes creating an environment that supports the infant's developmental needs, including family-centered care, a healing environment, and promoting protected sleep. Payment scale considerations are not a component of developmental care.

4. When caring for an infant with respiratory syncytial virus (RSV), which of the following actions should the nurse take?

A. Administer antibiotics IM once per day.
B. Initiate droplet precautions.
C. Place the infant in a negative-pressure isolation room.
D. Suction the nasopharynx as needed.

Correct answer: D

Rationale: When caring for an infant with respiratory syncytial virus (RSV), maintaining a patent airway is crucial. Suctioning the nasopharynx as needed helps clear secretions, prevent airway obstruction, and promote effective breathing. This intervention can aid in improving the infant's respiratory status and overall comfort. Administering antibiotics IM once per day (Choice A) is not indicated for RSV as it is caused by a virus, not bacteria. Initiating droplet precautions (Choice B) is important to prevent the spread of respiratory infections like RSV, but directly caring for the infant involves more specific interventions. Placing the infant in a negative-pressure isolation room (Choice C) is generally reserved for airborne infections, not RSV which spreads through respiratory droplets.

5. The healthcare provider is planning care for a patient receiving morphine sulfate via a patient-controlled analgesia pump. Which intervention may be required due to a potential adverse effect of this drug?

A. Administering a cough suppressant
B. Inserting a Foley catheter
C. Administering an anti-diarrheal
D. Monitoring urinary output

Correct answer: B

Rationale: Morphine can lead to urinary retention and urinary hesitancy. If a patient shows signs of bladder distention or inability to void, the healthcare provider should be notified, and urinary catheterization may be necessary. Administering a cough suppressant or an anti-diarrheal is not typically required to address adverse effects of morphine. Liver function tests (LFTs) are not directly related to the potential adverse effects of morphine on the urinary system.