Nokea
A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?
- A. A booster shot is required yearly.
- B. Additional injections are given at one and six months.
- C. Repeat doses are given at two and four months.
- D. Revaccination is not required.
Correct Answer: B
Rationale: hepatitis B vaccine is repeated at one and six months
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The nurse is obtaining a health history on a client in the medical clinic. The client states, 'I think I have an ulcer.' Which of the following responses by the nurse is BEST?
- A. Do you have a burning pain in the epigastric region?
- B. Do you have sharp pain in your lower abdomen?
- C. Do you have right shoulder pain with vomiting?
- D. Do you have heartburn when you lie down?
Correct Answer: A
Rationale: Burning epigastric pain is a classic ulcer symptom, guiding further assessment. Options B, C, and D suggest other conditions.
The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
The nurse is teaching a client with a new diagnosis of osteoporosis about calcitonin (Miacalcin). Which of the following statements by the client indicates a need for further teaching?
- A. I should report nasal irritation to my doctor.
- B. I should take this medication at bedtime.
- C. I should alternate nostrils when using the nasal spray.
- D. I should stop this medication if my bone density improves.
Correct Answer: D
Rationale: Stopping calcitonin when bone density improves is incorrect, as osteoporosis often requires ongoing treatment to maintain bone health. Options A, B, and C are correct: nasal irritation is a side effect, bedtime dosing is standard, and alternating nostrils prevents irritation.
A client has an order for furosemide (Lasix) 40 mg IV push via a heparin lock. Which of the following nursing actions would be MOST appropriate?
- A. Use a 16- to 18-gauge 1-in needle for administration.
- B. Administer the medication over one to two minutes.
- C. One cc of 1:1,000 heparin flush should be administered before the medication.
- D. A primary IV should be started prior to medication administration.
Correct Answer: B
Rationale: furosemide (Lasix) given IV push should be administered slowly over one to two minutes
A client is admitted with a suspected pulmonary embolism. Which of the following diagnostic tests should the nurse anticipate being ordered?
- A. Chest X-ray.
- B. D-dimer blood test.
- C. Echocardiogram.
- D. Arterial blood gas analysis.
Correct Answer: B
Rationale: D-dimer is a specific test to detect blood clots, highly sensitive for pulmonary embolism