Nokea
A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.
- A. 4-month-old client who is receiving scheduled vaccinations
- B. 3-year-old client who is afraid of needles
- C. 24-year-old client who is 6 weeks postpartum
- D. 32-year-old client who is pregnant at 12 weeks gestation
- E. 45-year-old client with a history of HIV
Correct Answer: B, C
Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (B) and postpartum client (C). It's contraindicated for infants under 2 (A), pregnant women (D), and immunocompromised clients (E).
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The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.
Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.
- A. Apply sterile gloves before providing client care.
- B. Request that the client be placed in a private room.
- C. Use an alcohol-based hand sanitizer for hand hygiene.
- D. Wear a single-use, protective gown when providing client care.
- E. Ensure surgical masks are worn by staff members who enter the client's room.
Correct Answer: B, D
Rationale: A private room (B) and protective gown (D) are required for contact precautions. Sterile gloves (A) are unnecessary, alcohol-based sanitizer (C) is ineffective against C. difficile spores, and surgical masks (E) are not required.
A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.
A client is admitted with Parkinson's disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be the most important to report?
- A. Dry mouth
- B. Spasmodic eye winking
- C. Dark urine
- D. Dizziness
Correct Answer: B
Rationale: Spasmodic eye winking could indicate a toxicity or overdose and should be reported to the physician. Other signs of toxicity include involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are incorrect because they are side effects of the drug.