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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Scrambled eggs with roasted peppers and onions, lean ham, and toast. While peppers and onions provide antioxidants, the presence of processed meat (ham) increases the risk of some cancers, particularly colorectal cancer, due to nitrates and preservatives.
B. Pancakes with blueberries and maple syrup, and a turkey sausage patty. Blueberries are rich in antioxidants, which can help reduce cancer risk, but pancakes with syrup are high in refined carbohydrates and added sugars, which may contribute to inflammation and increased cancer risk.
C. Oatmeal with raisins and nuts, with skim milk and 1/2 grapefruit. Oatmeal contains fiber, which helps reduce the risk of colorectal cancer. Raisins and nuts provide antioxidants, while grapefruit is high in vitamin C, which supports immune function and may help protect against some cancers. This is the best balanced meal with cancer-protective nutrients.
D. Poached egg, bacon, biscuit, and canned peaches in light syrup. Bacon is a processed meat linked to an increased risk of colorectal cancer. Biscuits are refined carbohydrates, and canned peaches in syrup contain added sugars, which can contribute to inflammation and chronic disease risk.
Correct Answer is A
Explanation
A. Increase in interstitial osmotic pressure due to cellular damage. A crushing injury damages cells, leading to the release of intracellular proteins and solutes into the interstitial space. This increases interstitial osmotic pressure, drawing fluid from the blood vessels into the injured tissues, causing edema. The inflammatory response further contributes to capillary permeability and fluid leakage.
B. Decrease in interstitial pressures due to low blood pressure. Blood pressure does not directly regulate interstitial pressure in a localized trauma area. Even if systemic blood pressure were low, localized edema can still occur due to tissue damage and increased capillary permeability.
C. Increased intravascular osmotic pressure due to crushing injury. Osmotic pressure in the blood is primarily determined by plasma proteins, such as albumin. A crushing injury does not increase intravascular osmotic pressure; instead, it increases interstitial osmotic pressure, pulling fluid out of the blood vessels.
D. Increased intravascular hydrostatic pressure due to trauma. While trauma can cause localized vascular changes, hydrostatic pressure primarily affects systemic circulation. In this case, localized tissue damage and inflammation—not increased intravascular pressure—are responsible for edema formation.
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