Nokea
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.
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All of the following clients are on the unit. Which one is most likely to develop urinary retention?
- A. A woman who had a modified radical mastectomy yesterday
- B. A man who had an abdominal cholecystectomy this morning
- C. A woman who had an abdominal hysterectomy yesterday
- D. A man who had surgery for a ruptured appendix
Correct Answer: C
Rationale: Abdominal hysterectomy involves pelvic manipulation, increasing urinary retention risk due to bladder trauma or nerve disruption. Other surgeries pose lower risk.
The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver?
- A. It measures a child's intelligence.
- B. It assesses a child's development.
- C. It evaluates psychological responses.
- D. It helps to determine problems.
Correct Answer: B
Rationale: It assesses a child's development. The Denver test screens for developmental milestones in young children.
A client with diabetes phones the clinic stating, 'I have a terrible cold and I don't know what to do about taking my insulin.' Which of the following should be included in the nurse's teaching regarding the client's insulin needs?
- A. Infections decrease insulin needs, so she should withhold insulin injections until her cold symptoms improve.
- B. Infections cause a drop in blood glucose levels, so she should base her insulin needs on the results of urine glucose tests.
- C. Infections cause alterations and increase insulin needs, so she should check her blood glucose levels and urine ketones at least every 4 hours.
- D. Infections cause no change in insulin requirements, but she should avoid crowds and overfatigue.
Correct Answer: C
Rationale: Infections increase insulin resistance, raising insulin needs. Frequent glucose and ketone monitoring ensures proper management. Withholding insulin or relying on urine tests is dangerous, and infections do alter insulin requirements.
The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.
- A. Apply a water-soluble lubricating agent to moisturize mouth tissue
- B. Avoid hot liquids and foods that are spicy or acidic
- C. Brush your teeth with a soft-bristle toothbrush
- D. Cleanse the mouth with saline after meals and at bedtime
- E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
Correct Answer: A,B,C,D
Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.
The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.