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A healthcare provider is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?
- A. The possibility of pregnancy within 4 weeks
- B. Client allergy to strawberries
- C. Client history of genital herpes
- D. The possibility of overseas travel in the next month
Correct Answer: A
Rationale: The correct answer is A. Pregnancy or the possibility of pregnancy within 4 weeks is a contraindication for receiving the MMR vaccine. Choice B, client allergy to strawberries, is not a contraindication to the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication to the MMR vaccine.
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A client is receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
- A. Slow the infusion and continue to monitor the site
- B. Stop the infusion
- C. Apply a warm compress to the site
- D. Apply a cold compress to the site
Correct Answer: B
Rationale: When an IV site appears infiltrated, it indicates that the medication is leaking into the surrounding tissues. In such a situation, the infusion should be stopped immediately to prevent further tissue damage. Choice A is incorrect because slowing the infusion would still allow the medication to leak into the tissues. Choices C and D are also incorrect as applying compresses can exacerbate the tissue damage caused by infiltration.
A nurse has provided education to a client regarding prescribed levothyroxine sodium. Which of the following client statements demonstrates understanding of medication administration?
- A. I should take my medication as needed to alleviate symptoms
- B. I should take the medication in divided doses to ensure therapeutic drug levels
- C. I should take the medication in the morning to prevent insomnia
- D. I should take the medication on a full stomach
Correct Answer: C
Rationale: Levothyroxine should be taken once in the morning to prevent insomnia and maintain therapeutic levels.
A nurse is caring for a client receiving theophylline for chronic obstructive pulmonary disease (COPD). Which of the following client findings indicates the need for immediate intervention?
- A. Productive cough
- B. Drowsiness
- C. Vomiting
- D. Polyuria
Correct Answer: D
Rationale: Polyuria is a sign of theophylline toxicity and requires immediate intervention. Theophylline toxicity can lead to serious complications, and polyuria is a concerning symptom that indicates the need for urgent medical attention. Productive cough, drowsiness, and vomiting are common side effects of theophylline but are not typically indicative of immediate life-threatening issues like polyuria in the context of theophylline toxicity.
A client has been prescribed metoclopramide. Which of the following should the nurse include in client education regarding this medication?
- A. Notify your provider if you experience restlessness or spasms of the face or neck
- B. This medication can cause insomnia
- C. Decrease your fluid intake while taking this medication
- D. This medication can cause urinary frequency
Correct Answer: A
Rationale: The correct answer is A: 'Notify your provider if you experience restlessness or spasms of the face or neck.' Metoclopramide can lead to extrapyramidal symptoms such as restlessness or facial spasms, which are serious and require immediate medical attention. Choices B, C, and D are incorrect. Insomnia is not a common side effect of metoclopramide. Increasing fluid intake is usually recommended to prevent dehydration caused by potential side effects like diarrhea. Urinary frequency is not a typical side effect associated with metoclopramide.
A healthcare provider has just administered a wrong medication to a client. Which of the following actions should the provider take next?
- A. No action is needed
- B. Report error to the provider
- C. Complete an institutional incident report
- D. Inform the client that the wrong medication was given
Correct Answer: B
Rationale: In the scenario where a wrong medication has been administered, it is crucial for the healthcare provider to report the error to the provider. This action is essential to ensure that the provider is informed promptly, corrective measures are taken, and the client's well-being is safeguarded. Choice A is incorrect as taking no action could lead to serious consequences and compromise patient safety. Choice C, while important, should come after reporting the error to the provider. Choice D is not the immediate priority as the provider should first focus on addressing the error internally.