Nokea
The nurse is caring for a client at 12 weeks gestation who has a rubella titer status of nonimmune. Which of the following actions should the nurse anticipate implementing?
- A. Administering measles-mumps-rubella (MMR) vaccine now
- B. Administering MMR vaccine immediately postpartum
- C. Administering MMR vaccine in the third trimester
- D. Informing the client that an MMR vaccine is not indicated
Correct Answer: B
Rationale: MMR is contraindicated during pregnancy due to risks to the fetus. Administering it postpartum ensures immunity for future pregnancies without harming the current pregnancy.
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A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
- A. How to take own pulse
- B. Monitoring daily weight
- C. Need for monthly International Normalized Ratio testing
- D. Need to increase foods high in potassium
- E. Reduction of sodium in diet
- F. Use of home oxygen
Correct Answer: A,B,E
Rationale: Taking pulse (A), monitoring weight (B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?
- A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours
- B. Client with a do-not-resuscitate prescription who has swelling at the IV site
- C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago
- D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag
Correct Answer: A
Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.
Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?
- A. Client with blood pressure of 90/70 mm Hg and deviated trachea
- B. Client with concussion who was unconscious for 5 minutes
- C. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg
- D. Client with pain at the thoracic spine and complete paralysis of both legs
Correct Answer: A
Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.