A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client.
The client tells the nurse, "I no longer want to receive this vaccine."

Which of the following responses should the nurse make?

"If I were you, I would get the vaccine to keep my family safe.”

"Influenza can be very serious to anyone who does not receive the vaccine.”

"The influenza vaccine is strongly encouraged, but I understand you would like to decline right now.”

"The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form.”

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale:

This response is not appropriate because it is judgmental and may make the client feel defensive.
It is important for the nurse to respect the client's right to make their own decisions about their health care.
Telling the client what they should do can undermine their autonomy and potentially damage the nurse-client relationship.
It's crucial for the nurse to remain objective and avoid imposing their personal opinions or beliefs onto the client.

Choice B rationale:

This response is also not appropriate because it is using scare tactics to try to persuade the client to get the vaccine.
This approach can be counterproductive and may further alienate the client.
It's important to provide accurate information about the risks and benefits of the vaccine in a neutral and non-threatening manner.

Choice C rationale:

This is the most appropriate response because it acknowledges the client's right to refuse the vaccine while still encouraging them to get it.
It also demonstrates respect for the client's autonomy and validates their feelings.
This approach is more likely to foster a positive nurse-client relationship and keep the door open for future discussions about vaccination.

Choice D rationale:

This response is not accurate because the influenza vaccine is not mandatory for all clients before discharge.
It is important for the nurse to provide accurate information to the client.
Threatening the client with an against medical advice form is not appropriate and may be considered a form of coercion.

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Correct Answer is C

Explanation

Metformin is an antidiabetic agent used to treat type 2 diabetes mellitus.

It works by decreasing carbohydrate absorption from the gut, increasing glucose uptake in peripheral tissues in the presence of insulin, and reducing hepatic gluconeogenesis.

In normal patients, metformin ingestion is not associated with hypoglycemia.

However, it is still important to check the client’s glucose level to ensure that it is within a safe range.

Choice A is wrong because collecting the client’s uric acid level is not necessary after accidental administration of metformin.

Choice B is wrong because obtaining the client’s HDL level is not necessary after accidental administration of metformin.

Choice D is wrong because monitoring the client’s thyroid function levels is not necessary after accidental administration of metformin.

A. Instruct the client to obtain annual immunizations. B. Monitor the client for hypotension. C. Monitor the client frequently for episodes of hypoglycemia. D. Instruct the client to consume a diet high in calcium.

Correct Answer is D

Explanation

Long-term use of prednisone can lead to a decrease in bone density and an increased risk of osteoporosis.

Consuming a diet high in calcium can help to maintain bone health and reduce the risk of osteoporosis.

Choice A is wrong because while it is important for individuals taking prednisone to receive immunizations, they should not receive live vaccines due to the immunosuppressive effects of prednisone.

Choice B is wrong because prednisone can cause hypertension, not hypotension.

Choice C is wrong because prednisone can cause hyperglycemia, not hypoglycemia.

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A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client. The client tells the nurse, "I no longer want to receive this vaccine." Which of the following responses should the nurse make?

Nursing Test Bank

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A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client.
The client tells the nurse, "I no longer want to receive this vaccine."

Which of the following responses should the nurse make?