Nokea
The nurse is preparing to administer influenza vaccines to a group of elderly clients in a long-term care facility. Which client should the nurse question receiving the vaccine?
- A. The client diagnosed with congestive heart failure.
- B. The client with a documented allergy to eggs.
- C. The client who has had an anaphylactic reaction to penicillin.
- D. The client who has an elevated blood pressure and pulse.
Correct Answer: B
Rationale: Influenza vaccines are often grown in eggs, making egg allergy (B) a contraindication due to anaphylaxis risk. Congestive heart failure (A), penicillin allergy (C), and elevated vitals (D) are not contraindications for the flu vaccine.
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The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions?
- A. Telling the client to take deep breaths
- B. Striking the back with a cupped hand
- C. Applying pressure below the diaphragm
- D. Placing the client in a sitting position
Correct Answer: B
Rationale: Striking the back with a cupped hand (percussion) helps loosen secretions during postural drainage.
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
- A. The client's lungs have reexpanded.
- B. There is an obstruction in the tubing coming from the client.
- C. There is a mechanical problem in the pump.
- D. Air is leaking into the drainage apparatus.
Correct Answer: A
Rationale: No bubbling in the water seal chamber typically indicates lung reexpansion, as air is no longer leaking from the lung into the pleural space.
Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
- A. The patient reports pain when the foot is manually dorsiflexed.
- B. The patient reports pain when the foot is manually plantarflexed.
- C. The patient experiences pain when the leg is extended.
- D. the patient experiences pain when the leg is flexed.
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS?
- A. An aminoglycoside antibiotic.
- B. A synthetic surfactant.
- C. A potassium cation.
- D. A nonsteroidal anti-inflammatory drug.
Correct Answer: B
Rationale: Synthetic surfactant (B) improves lung compliance in ARDS. Antibiotics (A), potassium (C), and NSAIDs (D) are not standard treatments.