Nokea
A nurse is caring for a client who is immunosuppressed. The nurse should identify that which of following immunizations is contraindicated for this client?
- A. Pneumococcal
- B. Meningococcal
- C. Inactivated influenza
- D. Varicella
Correct Answer: D
Rationale: The correct answer is D: Varicella. The client is immunosuppressed, so live vaccines like varicella should be avoided to prevent potential complications. Live vaccines can cause infection in immunocompromised individuals. Pneumococcal, Meningococcal, and Inactivated influenza vaccines are safe for immunosuppressed clients as they are not live vaccines. Varicella is contraindicated due to the risk of causing varicella infection in an immunocompromised individual.
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A nurse is reinforcing teaching with the parents of a 1-year-old client following the administration of the measles, mumps, and rubella virus vaccine (MMR). Which of the following adverse effects should the nurse instruct the parents to report to the provider?
- A. Glandular swelling around the jaw
- B. Redness around the injection site
- C. Temperature 37.3° C (99.2° F)
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. Shortness of breath can indicate a severe allergic reaction or anaphylaxis, which is a rare but serious adverse effect of the MMR vaccine. It is crucial to report this immediately to the healthcare provider for prompt evaluation and management to prevent any complications.
A: Glandular swelling around the jaw is a common and mild side effect of the MMR vaccine, typically resolving on its own and not requiring immediate medical attention.
B: Redness around the injection site is a common and expected reaction to the vaccine, usually resolving without intervention.
C: A temperature of 37.3° C (99.2° F) is a low-grade fever, which can be a normal response to vaccination and typically does not require urgent medical attention.
A nurse is collecting data from a client who is taking ferrous sulfate. The nurse should report which of the following findings as an adverse effect of this medication?
- A. Tinnitus
- B. Hot flashes
- C. Diplopia
- D. Epigastric pain
Correct Answer: D
Rationale: The correct answer is D: Epigastric pain. Ferrous sulfate is an iron supplement commonly known to cause gastrointestinal side effects, such as epigastric pain, nausea, and constipation. The rationale behind this is that iron can irritate the stomach lining, leading to discomfort or pain in the epigastric region. Tinnitus (A), hot flashes (B), and diplopia (C) are not typically associated with ferrous sulfate administration. Tinnitus is more commonly linked to aspirin toxicity, hot flashes are often related to hormonal changes, and diplopia is a symptom of various neurological conditions. Thus, the nurse should report epigastric pain as a potential adverse effect of ferrous sulfate.
A nurse is collecting data from a client who is taking lithium carbonate to treat bipolar disorder. For which of the following findings should the nurse monitor and report to the provider?
- A. Bruising
- B. Tremor
- C. Constipation
- D. Hypoglycemia
Correct Answer: B
Rationale: The correct answer is B: Tremor. Lithium carbonate is commonly associated with causing tremors as a side effect. The nurse should monitor and report any tremors in the client taking lithium as it could indicate lithium toxicity. Bruising (A), constipation (C), and hypoglycemia (D) are not typically associated with lithium carbonate use in treating bipolar disorder.
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. Inject the medication at least 5 cm (2 in) from the umbilicus.
- B. Administer the medication with a 27-gauge /0.5 inch needle.
- C. Use the Z-track technique to administer the medication.
- D. Give the medication without aspirating prior to injection.
Correct Answer: C
Rationale: The correct answer is C: Use the Z-track technique to administer the medication. The Z-track technique involves pulling the skin laterally before injecting the medication to prevent leakage and irritation. This is crucial when administering IM injections to prevent the medication from leaking into the subcutaneous tissue. Option A is incorrect because the injection site for IM injections should be at least 2.5 cm (1 inch) away from the umbilicus. Option B is incorrect because a larger needle gauge (e.g., 22-25 gauge) is typically used for IM injections to reduce discomfort and prevent medication leakage. Option D is incorrect because aspirating prior to injection is not necessary for IM injections and may cause tissue damage.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should increase the sodium in my diet.
- B. I will report a sore throat to my provider.
- C. I will take this medication on an empty stomach.
- D. I should watch for weight loss.
Correct Answer: B
Rationale: The correct answer is B: "I will report a sore throat to my provider." This is because prednisone can suppress the immune system, increasing the risk of infections like sore throat. Reporting any signs of infection promptly is crucial. Choice A is incorrect because prednisone can cause sodium retention, so increasing sodium intake is not recommended. Choice C is incorrect as prednisone is usually taken with food to minimize stomach irritation. Choice D is incorrect because weight gain is more common with prednisone due to fluid retention.