An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Offer to also administer a meningococcal vaccine to the client.

Record height, weight, and vital signs before giving the vaccine.

Ask if the client's influenza exposure was within the last week.

Review the client's vaccination history in the electronic record.

Answer and Explanation

The Correct Answer is D

A. Offer to also administer a meningococcal vaccine to the client. The meningococcal vaccine is not routinely recommended for older adults unless they are at increased risk (e.g., immunocompromised, asplenic, or in certain outbreak situations). The priority is ensuring the influenza vaccine is appropriate based on the client’s history.
B. Record height, weight, and vital signs before giving the vaccine. Routine height, weight, and vital signs are not necessary before administering an influenza vaccine unless the client has symptoms of illness. The focus should be on vaccination history and contraindications.
C. Ask if the client's influenza exposure was within the last week. Recent exposure to influenza does not contraindicate vaccination. The vaccine is preventive and does not provide immediate protection, so the client should still receive it to help prevent future infection.
D. Review the client's vaccination history in the electronic record. Checking vaccination history ensures the client is receiving the correct vaccine and has not already been vaccinated for the season. This helps prevent unnecessary repeat doses and ensures adherence to recommended immunization schedules.

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Correct Answer is ["C","D","F","G"]

Explanation

Heart rate 88 beats/minute: This is within the normal range (60-100 bpm) and does not require immediate intervention.

Blood pressure 122/72 mm Hg: This is within a normal range and does not indicate an urgent issue.

Temperature 100.5°F (38°C): An elevated temperature suggests a possible infection, such as cellulitis or deep vein thrombosis (DVT), which requires further evaluation.

Reports of pain with ambulation: Pain with walking, especially in a client with peripheral vascular disease and diabetes, may indicate worsening circulation, infection, or DVT.

Respirations 20 breaths/minute: This is within the normal range (12-20 breaths/minute) and does not require immediate intervention.

Left lower leg with erythema, warm, and swollen: These are signs of inflammation or infection, such as cellulitis or a possible DVT, both of which require urgent medical attention.

Blood glucose 252 mg/dL (13.9 mmol/L): Elevated blood glucose can impair wound healing, increase the risk of infection, and contribute to further complications in a client with diabetes.

A. Offer a low sodium formula between breast feedings. B. Stimulate the infant during feedings to ensure adequate intake. C. Administer supplemental thyroid hormone daily. D. Monitor the infant's daily intake and weekly weight.

Correct Answer is C

Explanation

A. Offer a low sodium formula between breast feedings. Congenital hypothyroidism is not managed with dietary sodium restrictions. The priority is thyroid hormone replacement, not sodium intake adjustments.
B. Stimulate the infant during feedings to ensure adequate intake. Infants with congenital hypothyroidism may have poor feeding due to lethargy, but stimulation during feedings is not the primary intervention. The most critical aspect of care is thyroid hormone replacement to support normal growth and brain development.
C. Administer supplemental thyroid hormone daily. Lifelong thyroid hormone replacement with levothyroxine is essential to prevent intellectual disability and growth delays. Early and consistent treatment ensures normal neurological and physical development. Missing doses or delaying treatment can result in irreversible cognitive impairment.
D. Monitor the infant's daily intake and weekly weight. While monitoring growth and nutrition is important, it is secondary to ensuring proper thyroid hormone therapy, which directly affects metabolism, weight gain, and developmental outcomes.

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An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","F","G"]

Explanation

Correct Answer is C

Explanation

Which histologic finding in an affected area of the body suggests the presence of an inflammatory process?

A client receives a prescription for 500 mL of lactated Ringer's IV to be infused over 4 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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