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The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
- A. Egg allergy is a contraindication to giving this vaccine.
- B. This is a three-series vaccine that should be started at birth.
- C. It is safe for breastfeeding women to receive the MMR vaccine.
- D. This vaccine is safe if the client is pregnant.
Correct Answer: C
Rationale: The MMR vaccine is safe for breastfeeding women but contraindicated in pregnancy and not started at birth. Egg allergy is no longer a contraindication.
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The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.
The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?
- A. Sterile gloves should be used to perform urinary catheter care.
- B. Urinary specimens may be collected from a catheter bag.
- C. You may irrigate a catheter with warm water for poor outflow.
- D. Daily use of soap and water should be used around the urinary meatus.
Correct Answer: D
Rationale: Daily soap and water cleaning around the urinary meatus prevents infection. Sterile gloves are not required, specimens from catheter bags are unreliable, and irrigation requires a prescription.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 5 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse has received orders from the physician. Select three (3) orders that the nurse should consider a priority.
- A. insert peripheral vascular access device
- B. serum type and screen
- C. transfuse two units of fresh frozen plasma
- D. perform a bedside swallow evaluation
- E. apply sequential compression devices
- F. obtain a complete metabolic panel
Correct Answer: A, B, C
Rationale: Peripheral access, serum type and screen, and FFP transfusion are priorities to manage bleeding risk from subarachnoid hemorrhage and elevated INR.
The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication?
- A. Multivitamin
- B. Aspirin
- C. Warfarin
- D. Simvastatin
- E. Salmeterol
Correct Answer: A, E
Rationale: Multivitamins address malabsorption, and salmeterol helps manage airway obstruction in cystic fibrosis.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. captopril for a client with congestive heart failure
- B. metoprolol for a client with multiple premature ventricular contractions (PVCs)
- C. verapamil for a client with atrial fibrillation
- D. spironolactone for a client with end-stage renal disease
Correct Answer: D
Rationale: Spironolactone can cause hyperkalemia, which is dangerous in end-stage renal disease, and should be questioned.