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A nurse is assessing for allergies with a client who is scheduled to receive the influenza vaccine. Which of the following allergies should the nurse report to the provider as a possible contraindication to receiving the vaccine?
- A. Eggs
- B. Shellfish
- C. Peanuts
- D. Milk
Correct Answer: A
Rationale: The correct answer is A: Eggs. Influenza vaccines are typically produced using eggs, so individuals with egg allergies may have an allergic reaction to the vaccine. Reporting this allergy to the provider is crucial to avoid potential adverse reactions. Shellfish, peanuts, and milk allergies are not contraindications for receiving the influenza vaccine. Summary: Eggs are the correct answer due to the vaccine production method; shellfish, peanuts, and milk allergies are not relevant in this context.
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A nurse is preparing to administer subcutaneous heparin to a client. Which of the following should the nurse take?
- A. Massage the site after administering the medication
- B. Use a 21-gauge needle for the injection
- C. Aspirate before injecting the medication
- D. Insert the needle at least 5 cm (2 in) from the umbilicus
Correct Answer: D
Rationale: The correct answer is D: Insert the needle at least 5 cm (2 in) from the umbilicus. This is crucial to prevent any potential harm to the abdominal organs located around the umbilicus. Inserting the needle too close could lead to injury or bleeding. Massaging the site after administering (A) is not recommended as it can cause bruising or discomfort. Using a 21-gauge needle (B) is not specified for subcutaneous heparin injections. Aspirating before injecting (C) is not necessary for subcutaneous injections, as the risk of hitting a blood vessel is low.
A nurse is preparing to administer 4,000 units of heparin subcutaneously to a client who has deep-vein thrombosis. Available is heparin 10,000 units/mL. How many mL of heparin should the nurse administer? (Round to the nearest tenth.)
Correct Answer: 0.4
Rationale: To calculate the mL of heparin to administer, use the formula: desired dose (4,000 units) ÷ concentration (10,000 units/mL) = X mL. 4,000 ÷ 10,000 = 0.4 mL. The correct answer is 0.4 mL because it accurately represents the calculated dose needed for the client. Other choices are incorrect as they do not align with the correct calculation.
A nurse accidentally administers the medication metformin instead of metoprolol to a client. Which of the following actions should the nurse take?
- A. Monitor the client's thyroid function levels.
- B. Collect the client's uric acid level.
- C. Obtain the client's HDL level.
- D. Check the client's glucose level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's glucose level. Metformin is a medication used to treat diabetes, so administering it instead of metoprolol could lead to hypoglycemia. Checking the client's glucose level will help determine if the client is experiencing low blood sugar levels due to the medication error. Monitoring thyroid function (A), collecting uric acid levels (B), and obtaining HDL levels (C) are not relevant in this situation and would not address the immediate concern of potential hypoglycemia.
A nurse is caring for a client receiving gentamicin. Which of the following should the nurse monitor the client for?
- A. Prostephobia
- B. Tireibus
- C. Polyuria
- D. Tathyramda
Correct Answer: C
Rationale: The correct answer is C: Polyuria. Gentamicin is an antibiotic known to potentially cause kidney damage, leading to impaired kidney function and decreased urine output. Therefore, monitoring for polyuria (excessive urine output) is crucial to assess the client's renal function. Prostephobia, Tireibus, and Tathyramda are not known side effects or complications associated with gentamicin use. Prostephobia is not a medical term, and Tireibus and Tathyramda are not relevant to gentamicin therapy. The nurse should focus on monitoring the client for signs of kidney damage, such as changes in urine output, in this scenario.
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion.
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
- D. Obtain the first unit of packed RBCs from the blood bank.
- E. Start an IV bolus of lactated Ringer's solution.
Correct Answer: B
Rationale: [0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.