Nokea
A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?
- A. The client had a local reaction from a previous immunization
- B. The client reports having diarrhea this morning
- C. The client is at 9 weeks of gestation
- D. The client reports an allergy to penicillin.
Correct Answer: C
Rationale: The correct answer is C: The client is at 9 weeks of gestation. Administering the MMR vaccine during pregnancy is contraindicated due to the theoretical risk of causing harm to the fetus. The live attenuated MMR vaccine should not be given to pregnant women as it may potentially harm the developing fetus. It is crucial to avoid administration during pregnancy to prevent any adverse effects on the unborn child.
Other options are incorrect because:
A: The client had a local reaction from a previous immunization - Local reactions to previous vaccines are not contraindications to receiving the MMR vaccine.
B: The client reports having diarrhea this morning - Diarrhea is not a contraindication for the MMR vaccine.
D: The client reports an allergy to penicillin - Allergy to penicillin is not a contraindication for the MMR vaccine.
You may also like to solve these questions
A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?
- A. Jaundice
- B. Urticaria
- C. Bradycardia
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Urticaria. Urticaria, also known as hives, is a common manifestation of allergic reactions. It presents as raised, red, itchy welts on the skin. Jaundice (A) is associated with liver dysfunction, not typically an allergic reaction. Bradycardia (C) is a slow heart rate and not a common allergic reaction symptom. Hypertension (D) is high blood pressure and is not typically associated with allergic reactions. Therefore, based on the symptoms of an allergic reaction, urticaria is the most appropriate choice.
A nurse is caring for a client who is receiving heparin therapy. If the client requires a reversal of the effects of heparin, which of the following medications should the nurse expect the provider to prescribe?
- A. Atropine
- B. Vitamin K
- C. Vitamin B12
- D. Protamine
Correct Answer: D
Rationale: The correct answer is D: Protamine. Protamine is the antidote for heparin as it works by forming a complex with heparin, neutralizing its anticoagulant effects. Atropine (A) is used for bradycardia, not for heparin reversal. Vitamin K (B) is used to reverse the effects of warfarin, a different anticoagulant. Vitamin B12 (C) is not used for heparin reversal. Therefore, the correct choice is Protamine (D) for reversing heparin's effects.
A nurse is reinforcing teaching with a client who has COPD and has been taking long-term high doses of prednisone. Which of the following instructions should the nurse include in the teaching?
- A. Limit potassium-containing foods in your diet.'
- B. Withhold prednisone for 48 hours prior to receiving contrast dye.'
- C. Measure your blood glucose levels periodically.'
- D. Take prednisone on an empty stomach.'
Correct Answer: C
Rationale: The correct answer is C: Measure your blood glucose levels periodically. Clients taking long-term high doses of prednisone are at risk for developing steroid-induced diabetes due to the drug's effect on blood glucose levels. Monitoring blood glucose levels will help detect any abnormalities early, allowing for timely intervention.
A: Limiting potassium-containing foods is not directly related to prednisone use in COPD.
B: Withholding prednisone for 48 hours prior to receiving contrast dye can lead to adrenal insufficiency in clients on long-term prednisone therapy.
D: Taking prednisone on an empty stomach is not a specific instruction related to managing COPD or prednisone therapy.
A nurse is reinforcing discharge teaching with a client who has tuberculosis and a prescription for rifampin. Which of the following client statements indicates an understanding of the teaching?
- A. I can discontinue this medication after one negative sputum culture.'
- B. I should take this medication on an empty stomach.'
- C. I should expect to have ringing in my ears.'
- D. I can expect to have joint pain.'
Correct Answer: B
Rationale: The correct answer is B: "I should take this medication on an empty stomach." Rifampin should be taken on an empty stomach to maximize absorption. Taking it with food can decrease its effectiveness. Choice A is incorrect because rifampin treatment typically lasts several months, not just until one negative sputum culture. Choices C and D are incorrect as they are not common side effects of rifampin. The client should be informed about potential side effects, such as gastrointestinal upset or discoloration of bodily fluids, but not ringing in the ears or joint pain.
A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?
- A. Instruct the client's visitors not to operate the PCA pump.'
- B. Check the client's pain level every 8 hours.'
- C. Diarrhea is an adverse effect of morphine PCA.'
- D. Using morphine PCA increases the client's risk of toxicity.'
Correct Answer: A
Rationale: The correct answer is A, instruct the client's visitors not to operate the PCA pump. This is important to prevent unauthorized administration of medication by individuals who are not trained to use the PCA pump, ensuring patient safety. Checking the client's pain level every 8 hours (B) is important but not the priority in monitoring PCA. Diarrhea is not a common adverse effect of morphine PCA (C), and using morphine PCA does not inherently increase the client's risk of toxicity (D) if used appropriately.