A nurse is preparing to administer the influenza vaccine to a group of clients. For which of the following clients should the nurse withhold the vaccine?

A client who developed influenza after receiving the vaccine last year

A client who has hypertension

A client who has a history of Guillain-Barré syndrome

A client who has an allergy to dairy products.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.

Choice B rationale:

Hypertension is not a contraindication for receiving the influenza vaccine.

Choice C rationale:

Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.

Choice D rationale:

Allergies to dairy products are not a contraindication for receiving the influenza vaccine.

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Correct Answer is A

Explanation

Choice A rationale:

Melanoma often originates from an existing mole or can develop as a new pigmented lesion on the skin.

Choice B rationale:

Melanoma lesions are typically asymmetrical, not symmetrical.

Choice C rationale:

Metastasis of melanoma is not rare and can occur if the disease is not diagnosed and treated early.

Choice D rationale:

Melanoma has multiple growth phases, including radial and vertical growth.

A. Administer the phenytoin infusion over 5 min. B. Flush with 0.9% sodium chloride after administration. C. Flush with 100 units/mL of heparin after administration. D. Administer the phenytoin in 100 mL of D5W

Correct Answer is B

Explanation

Choice A rationale:

Phenytoin should be administered slowly to avoid adverse effects. Infusing 800 mg over 5 minutes is too rapid and can lead to cardiovascular complications.

Choice B rationale:

Rationale: After administering phenytoin via IV, it's important to flush the IV line with normal saline (0.9% sodium chloride) to ensure the medication is fully delivered to the client and to prevent any residual medication from precipitating in the IV line.

Choice C rationale:

Flushing with heparin is not standard practice for administering phenytoin.

Choice D rationale:

Phenytoin should be administered in normal saline, not in D5W (dextrose 5% in water), to avoid precipitation.

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A nurse is preparing to administer the influenza vaccine to a group of clients. For which of the following clients should the nurse withhold the vaccine?

Nursing Test Bank

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