The client tells the nurse. "I would like to get the vaccine for hepatitis C." Which response is the most appropriate by the nurse?
“The vaccination must be administered in two doses."
“Have you received the hepatitis B vaccination?"
“There is no vaccination against hepatitis C."
"Why are you interested in receiving this vaccine?"
The Correct Answer is C
A. “The vaccination must be administered in two doses.”: This assumes a hepatitis C vaccine exists and has a two-dose schedule; no licensed hepatitis C vaccine exists to have any dosing schedule.
B. “Have you received the hepatitis B vaccination?”: Hepatitis B does have a vaccine (so asking about it can be useful), but it does not answer the client’s request about hepatitis C. This response redirects rather than directly addressing the client’s statement.
C. “There is no vaccination against hepatitis C.”: This directly and accurately answers the client’s statement by stating that no vaccine currently exists for hepatitis C.
D. "Why are you interested in receiving this vaccine?": Acceptable as a follow-up question (explores risk/exposure), but it does not first correct the factual misunderstanding; best practice is to answer the factual question first, then explore motivations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Furosemide (Lasix): Loop diuretics lower calcium and are not the acute treatment for hypocalcemia after parathyroidectomy.
B. Calcium gluconate: Post-parathyroidectomy hypocalcemia (tetany, muscle cramps, paresthesias, cardiac arrhythmias) is treated emergently with IV calcium (calcium gluconate).
C. Diazepam (Valium): Diazepam is an anxiolytic/muscle relaxant but not the emergency treatment for hypocalcemia.
D. Potassium chloride: Potassium chloride does not treat hypocalcemia.
Correct Answer is A
Explanation
A. Serum potassium level WNL Digoxin given for rapid apical pulse: The serum K⁺ of 3.9 mEq/L is within normal range and the apical rate of 92 bpm is >60, so per usual digoxin administration guidelines the nurse may give the medication and document that K is WNL and digoxin was administered. (If the rhythm is an unexpected irregularity, the nurse would still note it and monitor/notify per facility policy.)
B. Digoxin withheld to prevent toxicity due to the low potassium level: The potassium value is not low (3.9 mEq/L is within normal limits), so withholding for low K⁺ is not indicated.
C. HCP informed of irregular HR and low serum potassium level: While informing the HCP of an irregular pulse may be appropriate, the serum potassium is not low, so documenting “low potassium” would be inaccurate.
D. Digoxin withheld because the client's apical HR is irregular: Irregular rhythm alone (with rate >60 and no other contraindications) is not an automatic reason to withhold digoxin; the usual criterion is to withhold for low heart rate (commonly <60) or other signs of toxicity.
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