A nurse is caring for a client in a primary care clinic who presents for a routine check-up and vaccination review. The client expresses concern about their immunization history, particularly regarding hepatitis vaccination. The nurse is tasked with reviewing the client's records and discussing any overdue vaccinations

Which nursing actions are anticipate and which are contraindicated.

Review client's immunization history to assess previous hepatitis B vaccine administration.

Advise the client to complete the three-dose hepatitis B vaccination series for optimal protection.

Provide education regarding the risk factors for hepatitis B transmission, such as exposure to infected blood and bodily fluids.

Recommend delaying the hepatitis B vaccine until the client has undergone hepatitis antibody testing.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Immunization assessment and appropriate nursing interventions for hepatitis B vaccination are vital for patients at risk. Hepatitis B is a viral infection transmitted through blood and body fluids, and vaccination is the primary method of prevention. Clients who have incomplete vaccination series require completion rather than delay, unless specific contraindications exist. Nursing care includes reviewing immunization history, educating about disease transmission, and ensuring timely vaccination to establish immunity.

Rationale:

• Review client's immunization history to assess previous hepatitis B vaccine administration: Reviewing immunization records is a foundational nursing responsibility to determine vaccination status and identify missing or incomplete doses. This ensures accurate assessment of immunity and prevents unnecessary delays in protection. In this case, the client has an incomplete hepatitis B series, making record review essential. It guides appropriate next steps in vaccination planning.

• Advise the client to complete the three-dose hepatitis B vaccination series for optimal protection: Completion of the hepatitis B vaccine series is necessary to achieve full and long-lasting immunity. A single dose does not provide adequate protection against infection. Since the client has only one documented dose, continuation of the series is recommended without restarting. This is standard preventive care in primary health settings.

• Provide education regarding the risk factors for hepatitis B transmission: Client education is essential to reduce exposure risk and promote understanding of disease prevention. Hepatitis B is transmitted through infected blood and body fluids, including sexual contact, needle sharing, and occupational exposure. Teaching reinforces the importance of vaccination and safe practices. This supports informed health decisions and prevention of infection.

• Recommend delaying the hepatitis B vaccine until the client has undergone hepatitis antibody testing: Delaying vaccination for routine antibody testing is not recommended in clients with incomplete immunization records and no contraindications. Hepatitis B vaccination can be safely administered without prior serologic testing in most cases. Delaying increases the risk of preventable infection.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["C","E"]

No explanation

A. Administer an anxiolytic. B. Administer sodium bicarbonate. C. Increase oxygen concentration. D. Decrease the respiratory rate of the mechanical ventilator.

Correct Answer is D

Explanation

The arterial blood gas (ABG) results indicate respiratory alkalosis, characterized by a high pH (7.5) and a low PaCO2 (28 mm Hg), while the bicarbonate remains within the normal range. In a client with pneumonia on mechanical ventilation, a respiratory rate of 34 breaths per minute suggests hyperventilation. Respiratory alkalosis occurs when excessive ventilation causes increased elimination of carbon dioxide from the body, leading to a rise in blood pH. In mechanically ventilated clients, this often results from hyperventilation due to excessive ventilator settings or patient distress.

Rationale:
A. Administering an anxiolytic may be helpful if anxiety is contributing to hyperventilation, but in this case the client is on mechanical ventilation, making ventilator settings the more direct and immediate cause to address. Priority should be given to correcting the mechanical source of excessive ventilation first. Sedation without adjusting ventilation may delay proper correction of the alkalosis.

B. Administering sodium bicarbonate is inappropriate because sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. This client already has an elevated pH of 7.5, indicating alkalemia, and giving bicarbonate would worsen the imbalance. The low PaCO2 confirms that the primary problem is excessive carbon dioxide loss rather than bicarbonate deficiency.

C. Increasing oxygen concentration is not the priority because the ABG findings indicate a ventilation problem rather than an oxygenation problem. The major abnormality is low PaCO2 caused by excessive respiratory rate, not evidence of hypoxemia. Raising oxygen concentration will not correct respiratory alkalosis and may expose the client to unnecessary oxygen-related complications.

D. Decreasing the respiratory rate of the mechanical ventilator is the priority intervention because it directly addresses the cause of respiratory alkalosis. A respiratory rate of 34 breaths per minute causes excessive carbon dioxide elimination, resulting in PaCO2 of 28 mm Hg and elevated pH. Lowering the ventilator rate helps retain carbon dioxide and gradually restores normal acid-base balance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements regarding the management of acute kidney rejection should the nurse include in client education? Select all that apply.

Correct Answer is ["C","E"]

A nurse is caring for a client with pneumonia who is on mechanical ventilation and exhibits a respiratory rate of 34 breaths per minute. The client's ABG results show a pH of 7.5, PaCO2 of 28 mm Hg, and HCO3 of 22 mEq/L. Which nursing action should be prioritized?

Correct Answer is D

Explanation

A client presents with symptoms of confusion, lethargy, and increased thirst. Laboratory tests reveal elevated serum calcium levels. Which intervention should the nurse prioritize based on the client's condition?

Which of the following statements about internal radiation therapy (brachytherapy) are accurate? Select All that Apply

A nurse is reviewing the laboratory values of a client with bone marrow suppression and is receiving epoetin alfa. Which of the following values would indicate an improvement in the client's condition?

A nurse is caring for a client in an outpatient clinic who is undergoing routine screenings and lifestyle counseling. The nurse emphasized the need for annual check-ups to monitor health status. What other primary cancer prevention strategies should the nurse include? Select all that apply.

Which of the following methods can be used to verify the correct placement of an endotracheal tube after intubation? Select All that Apply.

A client on mechanical ventilation has a high pressure alarm triggered. Which of the following actions should the nurse prioritize to address this alarm?

A nurse assesses a client who has experienced significant blood loss from a ruptured aneurysm. Which of the following findings would most likely indicate the client is experiencing hypovolemic shock?