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 B

Explanation

A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

The nurse recognizes that a diagnosis of cellulitis can be explained by assessment findings of red, warm, swollen lower left leg and a small coach (likely wound or abrasion) above the affected area.

Rationale:

Cellulitis is a bacterial skin infection that presents with localized redness, warmth, swelling, and pain.

Red, warm, swollen lower left leg indicates inflammation and infection, which are key signs of cellulitis.

A small coach (likely wound or abrasion) above the affected area suggests a potential entry point for bacteria, increasing the risk of infection.

The client's history of generalized muscle aches and not feeling well suggests systemic involvement, which is common in infections.

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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

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?

Correct Answer is B

Explanation

Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of dropdownbe explained by assessment findings of dropdownanddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

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