A nurse in a clinic is collecting data from a client. The client reports that they do not believe in receiving immunizations. Which of the following questions should the nurse ask the client?

What makes you believe that the science behind immunization is wrong

Is not taking the immunization worth the risk of getting very sick during flu season

"Why a you opposed to receiving immunization

what your biggest concern with receiving immunization

Answer and Explanation

The Correct Answer is D

A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.

B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.

C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.

D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.

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Correct Answer is C

Explanation

A) Check blood pressure for a client who is short of breath:
In a mass casualty incident, triage prioritizes addressing life-threatening conditions first. While shortness of breath may indicate a serious problem, assessing blood pressure would not be the most immediate action. The nurse should focus on airway, breathing, and circulation (the ABCs) before checking vital signs like blood pressure, as these could indicate the need for more urgent interventions.

B) Identify arterial bleeding by the presence of dark red blood:
Arterial bleeding is typically characterized by bright red blood that spurts or pulses with the heartbeat. Dark red blood is more indicative of venous bleeding. Recognizing arterial bleeding involves identifying the bright red, spurting blood, not dark red blood. It is essential to address major bleeding immediately by applying pressure or using a tourniquet as needed.

C) Open the airway of a client who has a cervical injury by using the jaw-thrust technique:
In clients with potential cervical spine injuries, the jaw-thrust technique is the recommended method to open the airway, as it does not involve tilting the head and neck, which could exacerbate a cervical injury. Ensuring the airway is patent is a priority in triage, and the jaw-thrust maneuver minimizes the risk of further injury to the spine.

D) Request the assistance of another staff member to log roll a client:
While log rolling is important for proper spinal alignment in clients with suspected spinal injuries, it is not the most urgent action during triage. In the context of a mass casualty incident, other immediate interventions, such as securing the airway and controlling bleeding, should take precedence before moving the patient unless the client’s condition requires repositioning to facilitate life-saving care.

A. pH 7.36 (7.35 to 7.45), PaCO2 38 mm Hg (35 to 45 mmHg) HCO3 25 mEq/L (22 to 26 mEq/L) B. pH 7.48 (7.35 to 7.45), PaCO, 32 mm Hg (35 to 45 mm Hg). HCO3 24 mEq/L (22 to 26 mE q/L) C. pH 7.46 (7.35 to 7.45). PaCO2 36 mm Hg (35 to 45 mm Hg). HCO3 29 mEq/L (22 to 26 mEq/L) D. pH 7.26 (7.35 to 7.45). PaCO, 35 mm Hg (35 to 45 mm Hg). HCO3 18 mEq/L (22 to 26 mEq/L)

Correct Answer is C

Explanation

A) pH 7.36 (7.35 to 7.45), PaCO2 38 mm Hg (35 to 45 mmHg), HCO3 25 mEq/L (22 to 26 mEq/L): This is a normal set of arterial blood gas (ABG) values, with a pH within normal range, a normal PaCO2, and a normal HCO3. It does not suggest metabolic alkalosis.

B) pH 7.48 (7.35 to 7.45), PaCO2 32 mm Hg (35 to 45 mm Hg), HCO3 24 mEq/L (22 to 26 mEq/L): Although the pH is elevated, indicating alkalosis, the PaCO2 is slightly low, and the bicarbonate (HCO3) is within the normal range. This set of values does not indicate metabolic alkalosis, but could indicate respiratory alkalosis or compensated alkalosis.

C) pH 7.46 (7.35 to 7.45), PaCO2 36 mm Hg (35 to 45 mm Hg), HCO3 29 mEq/L (22 to 26 mEq/L): This is consistent with metabolic alkalosis. The elevated pH (alkalosis) combined with an increased bicarbonate level (HCO3 > 26 mEq/L) and a normal PaCO2 suggests metabolic alkalosis, as the kidneys retain bicarbonate to compensate for the condition.

D) pH 7.26 (7.35 to 7.45), PaCO2 35 mm Hg (35 to 45 mm Hg), HCO3 18 mEq/L (22 to 26 mEq/L): This set of values indicates acidosis, not alkalosis. The pH is low, indicating acidosis, and the bicarbonate (HCO3) is also low, which suggests metabolic acidosis. The PaCO2 is normal, which further supports a metabolic origin of the acidosis.

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A nurse in a clinic is collecting data from a client. The client reports that they do not believe in receiving immunizations. Which of the following questions should the nurse ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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