Nokea
A nurse in an influenza clinic is collecting data from four clients. Which of the following clients should the nurse identify as having a contraindication for receiving the live attenuated form of the influenza vaccine?
- A. An adolescent who received a new tattoo last week
- B. A client is at 27 weeks of gestation
- C. A client who is about to travel to a different country
- D. A school-age child who has rhinitis
Correct Answer: B
Rationale: The correct answer is B - A client at 27 weeks of gestation. Pregnant individuals are contraindicated to receive live attenuated influenza vaccine due to theoretical risk to the fetus. This is because live vaccines are not recommended during pregnancy. Choice A is incorrect as a recent tattoo does not contraindicate the vaccine. Choice C is incorrect as travel plans do not affect the decision to administer the vaccine. Choice D is incorrect as rhinitis is not a contraindication.
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A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?
- A. Use the Z-track technique to administer the medication.
- B. Administer the medication with a 27-gauge 1/2-inch needle.
- C. Inject the medication at least 5 cm (2 in) from the umbilicus.
- D. Give the medication without aspirating prior to injection.
Correct Answer: A
Rationale: The correct answer is A: Use the Z-track technique to administer the medication. This technique helps prevent leakage of the medication into surrounding tissues by sealing the medication in the muscle. The Z-track method involves pulling the skin laterally before injecting the medication, then releasing the skin after the injection. This creates a zig-zag path that closes after the needle is withdrawn, reducing the risk of irritation or staining at the injection site. Choice B is incorrect because the needle size for IM injections in adults is typically 22-25 gauge and 1-1.5 inches long. Choice C is incorrect as IM injections should be administered at least 2.5 cm (1 inch) away from the umbilicus. Choice D is incorrect because aspiration (pulling back on the plunger to check for blood return) is not recommended for IM injections due to the risk of tissue trauma.
A nurse is collecting data from a client who is taking sumatriptan. Which of the following reports indicates a therapeutic response to the medication?
- A. Improved mood
- B. Absence of headache
- C. Increased bone mass
- D. Relief of chest pain
Correct Answer: B
Rationale: The correct answer is B: Absence of headache. Sumatriptan is commonly used to treat migraines. A therapeutic response would be the absence of headache, indicating that the medication is effectively managing the client's migraine symptoms. Improved mood (A) is not a direct indication of sumatriptan's effectiveness. Increased bone mass (C) is unrelated to sumatriptan's intended use for migraines. Relief of chest pain (D) is not a typical response to sumatriptan. Therefore, the absence of headache is the most relevant indicator of a therapeutic response to sumatriptan.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.
A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?
- A. Headache
- B. Polyuria
- C. Ringing in the ears
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Headache. Nitroglycerin transdermal patches can cause headaches as an adverse effect due to vasodilation leading to increased blood flow to the brain. This is a common side effect that may occur in patients using nitroglycerin. Polyuria (B) and ringing in the ears (C) are not common side effects of nitroglycerin. Increased blood pressure (D) is not an adverse effect of nitroglycerin; in fact, nitroglycerin decreases blood pressure by dilating blood vessels.
A nurse is caring for a client receiving gentamicin. For which of the following should the nurse monitor the client?
- A. Tinnitus
- B. Tachycardia
- C. Polyuria
- D. Photophobia
Correct Answer: A
Rationale: The correct answer is A: Tinnitus. The nurse should monitor the client for tinnitus because gentamicin can cause ototoxicity, leading to hearing loss and tinnitus. Tachycardia (B), polyuria (C), and photophobia (D) are not commonly associated with gentamicin use. Tachycardia may be a sign of other issues, polyuria could indicate kidney problems, and photophobia is sensitivity to light, which is not a typical side effect of gentamicin. Therefore, the nurse should focus on monitoring for tinnitus as a potential adverse effect of gentamicin therapy.