Nokea
The nurse is caring for a client who is 14 weeks pregnant. The client is asking about vaccinations that can be given during pregnancy. Which of the following vaccines does the nurse tell the client that are safe during pregnancy?
- A. mumps
- B. measles
- C. smallpox
- D. influenza
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy. Mumps, measles, and smallpox vaccines are contraindicated.
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The nurse is assessing for abdominal pulsations in a client with a visible mass below the umbilicus. The nurse should use which technique?
- A. light palpation
- B. inspection
- C. percussion
- D. deep palpation
Correct Answer: B
Rationale: Inspection is used to visually assess for abdominal pulsations or masses. Palpation or percussion may be used later but are not the initial technique for observing pulsations.
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:
- A. Notify the physician
- B. Make sure the catheter is patent
- C. Administer an antihypertensive
- D. Provide supplemental oxygen
Correct Answer: B
Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.
The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
- A. N. gonorrhea
- B. H. influenza
- C. H. pylori
- D. E. coli
Correct Answer: C
Rationale: H. pylori is a primary causative factor in peptic ulcers, contributing to mucosal damage and ulcer formation.
An RN notices an LPN in the medication room drawing up morphine. The RN asks the LPN who it is for. The LPN states that one of her clients needs pain medication. The RN offers to administer the dose, but the LPN says, 'It's ok. I can give it. I've had this client for several days and she is stable.' Which is the correct response by the nurse?
- A. Let me double-check the dose with you.
- B. OK, but let me know if you need help with anything.
- C. I am going to report this to the charge nurse immediately.
- D. You shouldn't do that. Let me chart it while you give it to save time.
Correct Answer: C
Rationale: LPNs typically cannot administer IV narcotics like morphine in most states due to scope of practice limitations. The RN should report this to the charge nurse for clarification and safety.
A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?
- A. drink orange juice to relieve discomfort
- B. drink extra milk to relieve discomfort
- C. avoid drinking from a straw
- D. rinse twice a day with antiseptic mouthwash
Correct Answer: C
Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.