With Correct Answers
The nurse is preparing to administer influenza vaccines to a mass drive-through clinic.
Which statement by a client would indicate further questioning prior to giving the client
the influenza vaccine?
1. "I am allergic to horse hair."
2. "I try to get my vaccine every year."
3. "I am not allergic to anything except eggs."
4. "My husband had a severe allergic reaction after he received his influenza
vaccine." - correct answer <<<<<💕💕💕✔✔Answer: 3
Rationale: Influenza vaccines are recommended for person at high risk for serious
sequelae of influenza. The nurse should be aware that client with a sensitivity to
eggs should not receive the vaccine. Vaccines prepared from chicken or duck
embryos are contraindicated in clients who are allergic to eggs.
Each client's response to pain may be influenced by multiple factors. Select all that
apply:
a. Age
b. Past experience with pain
c. Cultural influences
d. Knowledge - correct answer <<<<<💕💕💕✔✔Correct Answers: a; b; c; d
Rationale: All factors listed can influence a client's response to pain.
,The nurse is caring for four clients on a medical-surgical unit. The secretary gives the
nurse the morning labs. Which of the following labs would require that the nurse call the
physician and inform the healthcare provider about the client's abnormalities?
1. WBC 14,600 mm3
2. Serum protein 6.9 g/dL
3. I & D (incision and drainage) showing no growth for the last 24 hours
4. Albumin 4.2 g/dL - correct answer <<<<<💕💕💕✔✔Answer: 1
Rationale: When the nurse is caring for several clients, all of the labs should be checked
frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is
abnormal. (Normal WBC 4,000-10,000 mm3
.) All of the other lab results are within
acceptable range; therefore, the results should not be called in to the physician.
A 45-year-old woman presents to the ambulatory clinic for a gynecological
examination. The health history reveals no significant personal or family medical history.
What information concerning health-promotion behaviors should be presented to the
client?
a. It is time to begin having mammograms every other year.
b. If the client is in a monogamous relationship, Pap smears will not be needed.
c. Bone density examinations are indicated every year.
d. Recommended calcium intake is at least 1,200 mg per day. - correct answer
<<<<<💕💕💕✔✔Answer: d
,Rationale: The recommended calcium intake is at least 1,200 mg per day. This will be
beneficial in the prevention of osteoporosis. Women should begin having annual
mammograms by age 40. Pap smears are continued for women in monogamous
relationships. For women with no significant risk for the development of osteoporosis,
bone density examinations should be done every other year.
The admitting department alerts the nurse on a medical-surgical unit that a client with
active tuberculosis (TB) is being admitted to the unit. Which type of isolation is
appropriate based on the client's diagnosis?
1. Standard precautions
2. Airborne precautions
3. Droplet precautions
4. Contact precautions - correct answer <<<<<💕💕💕✔✔Answer: 2
In addition to handwashing and standard precautions, the nature and spread of some
infectious diseases require that special techniques be used to protect uninfected clients
and workers. The client with pulmonary tuberculosis will be placed in airborne
precautions. The client should be placed in a private room with special ventilation that
does not allow air to circulate to general hospital ventilation; a mask or special filter
respirators will be used for everyone entering the room.
A 75-year-old client seeks care at an ambulatory clinic. The client reports having
experienced extreme drowsiness after recently taking dosages of an over-the-counter cold
medication. When collecting data, the nurse notes the client reports taking only the
prescribed amount of the preparation. What inferences can be made by the nurse
concerning the events?
a. The client likely has taken more of the preparation than stated.
, b. The client likely has experienced a reaction between the cold medication and other
routine medications.
c. The client's age has influenced his response to the medication.
d. The client is allergic to the cold medication. - correct answer <<<<<💕💕💕✔✔Answer: c
Rationale: Older clients often experience altered responses to medications. These changes
are in response to age-related developments in the kidneys and liver. There is no evidence
the client has taken too much medication. There is no information provided to indicate
the client is taking other medications. Allergic reactions typically manifest with
integumentary- or respiratory-related symptoms.
The nurse is colleting data from a client regarding past alcohol use history. What
question will provide the greatest amount of information?
1. Are you a heavy drinker?
2. How often do you use alcohol?
3. Drinking doesn't cause any problems for you, does it?
4. Is alcohol use a concern for you? - correct answer <<<<<💕💕💕✔✔Answer: 2
Rationale: Open-ended questions will elicit the greatest amount of information. Asking
closed questions will limit the information obtained.
A client is receiving IV vancomycin for the treatment of Clostridium difficile. The
nurse understands that the client who develops flushing, tachycardia, and hypotension
during the infusion of vancomycin indicates:
1. Ototoxicity effect.
2. Superinfection.
3. Red man syndrome.