Question

A nurse is providing teaching about immunizations to a client is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

Answer 1

Correct Answers:

Inactivated influenza vaccine.
Tetanus, diphtheria and acellular pertussis vaccine

Rationale :

🩺Inactivated vaccines are considered safe for administration during pregnancy because they do not contain live organisms that can pose a risk to the developing fetus.

💉The inactivated influenza vaccine is recommended during any trimester of pregnancy to protect both the mother and fetus from serious complications of the flu.

🦠The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is also recommended between 27 and 36 weeks of gestation to enhance passive immunity in the newborn against pertussis.

🚫In contrast, live attenuated vaccines like rubella and varicella are contraindicated during pregnancy due to the risk of transmission to the fetus and potential teratogenic effects.

📌Core Message

Inactivated vaccines such as influenza and Tdap are safe during pregnancy, while live vaccines like rubella and varicella should be avoided due to fetal risk.

Answer 2

Correct Answers:

Infuse IV fluids.
Race the client on oxygen using a mask.
Stop cooling interventions once core temperature is 39°C (102°F).

Rationale :

🌡️Heat stroke is a medical emergency that requires aggressive temperature reduction and support of organ function.

💧IV fluids are essential to restore circulatory volume and prevent further complications such as hypovolemic shock.

😷Oxygen therapy supports oxygenation since hyperthermia increases metabolic demand, potentially leading to hypoxia.

🛑Cooling interventions should be discontinued at 39°C (102°F) to prevent induced hypothermia, which can cause complications like shivering that increases core temperature again.

🚫Antipyretics are not effective in heat stroke as the thermoregulatory center is impaired, and benzodiazepines are used if the client is shivering or seizing, so "avoid" is not a correct blanket action.

📌Core Message

In heat stroke, the nurse should ensure IV fluids, oxygenation, and discontinue cooling measures once the target core temperature is reached to prevent hypothermia.

Answer 3

Correct Answers:

Magazines are stacked neatly on the stairs.

Rationale :

📚Placing magazines or any items on the stairs poses a tripping hazard, especially in clients with mobility impairments like a hip fracture.

🧓Clients recovering from hip fractures are at high risk for falls, which can lead to further injury or surgical complications.

🔎A home safety assessment must identify environmental risks that can increase the likelihood of accidents.

🚫Even if stacked “neatly,” items on stairs should be removed entirely to ensure a clear, safe walking path.

📌Core Message

For a client with a hip fracture, stacked items like magazines on stairs present a fall risk and should be removed during a home safety assessment.

Answer 4

Correct Answers:

Take a hot every day.

Rationale :

💧Heat therapy such as warm showers can relieve joint stiffness and pain by increasing blood flow to the affected area.

🔥Clients with osteoarthritis often benefit from daily warm showers as part of their nonpharmacological pain management.

🚫Applying ice directly on skin can cause tissue damage and should be wrapped in cloth; pillows under knees cause joint flexion and can worsen contractures.

⚠️Phosphorus intake is not a key factor in managing osteoarthritis pain.

📌Core Message

Daily heat therapy such as warm showers supports pain relief and joint flexibility in clients with osteoarthritis.

Answer 5

Correct Answers:

Establish a patent airway.

Rationale :

🛑A client with head trauma and nasal bleeding is at risk of airway obstruction from blood or skull fracture–related complications.

💨Airway management is the first priority in any trauma following the ABC (Airway, Breathing, Circulation) framework.

🧠Bleeding from the nose after trauma could indicate basilar skull fracture, and manipulating the area without airway protection can increase risk.

🚨Other actions such as CT scan or IV insertion are important, but they follow after ensuring a patent airway.

📌Core Message

In head trauma, airway patency must be the first priority before any other intervention, especially when bleeding is present.

Answer 6

Correct Answers:

Determine if the AP has the skills to perform the test.

Rationale :

🔍Before delegating any task, the nurse must assess whether the assistive personnel (AP) is competent and trained to perform that task.

🩸Fasting blood glucose testing is delegable, but it requires skill validation due to the risk of improper technique or data error.

⚠️The nurse cannot assign the AP to check medical records or interpret data, which are nursing responsibilities.

🤝Safe delegation includes both right task and the right person, based on scope and competency.

📌Core Message

Delegation requires that the nurse confirms the AP’s competency before assigning a blood glucose test.

Answer 7

Correct Answers:

Fentanyl

Rationale :

💊Fentanyl is a potent opioid analgesic used for severe or acute exacerbation of chronic pain when non-opioids are insufficient.

🔥Chronic pain flares require stronger interventions, and fentanyl provides rapid and effective relief.

🛑Naloxone is a reversal agent and is not used for pain; acetaminophen is too mild for severe exacerbations.

😴Zolpidem is a sedative, not an analgesic, and does not treat pain.

📌Core Message

Fentanyl is appropriate for managing acute exacerbations of chronic pain due to its potency and effectiveness.

Answer 8

Correct Answers:

Check gastric residuals every 4 hr,
Maintain the head of the Clients bed at a 30° angle or higher.
Change the feeding container and tubing every 24hr.

Rationale :

🩺Checking gastric residuals helps assess tolerance to enteral feeding and risk for aspiration.

🛏️Elevating the head of bed 30° or higher minimizes the chance of regurgitation and aspiration pneumonia.

♻️Changing the feeding container and tubing every 24 hours reduces risk for bacterial contamination.

⚠️The formula should be warmed to room temperature, not ensured (incorrect phrasing), and x-ray confirmation is only done upon initial placement, not daily.

📌Core Message

During continuous enteral feeding, perform residual checks, maintain head elevation, and change tubing daily to prevent aspiration and infection.

Answer 9

Correct Answers:

“Biofeedback requires concentration to control physiological responses.”

Rationale :

🧘‍♀️Biofeedback is a technique that involves using conscious control over normally involuntary functions like heart rate, muscle tension, and breathing.

🧠The client learns to use visual or auditory feedback to control physiological responses through mental focus and relaxation.

🌿Biofeedback does not involve herbs or physical manipulation; it's a mind-body intervention.

🎯The goal is to enhance self-regulation and reduce dependence on pharmacologic therapy for issues like migraines.

📌Core Message

Biofeedback teaches clients to mentally regulate bodily responses, helping reduce migraine symptoms without medication.

Answer 10

Correct Answers:

Current nutritional status

Rationale :

🥗In adolescents who are pregnant, nutritional status has a direct impact on fetal development and maternal health.

🧪Inadequate nutrition during adolescence and pregnancy increases the risk for low birth weight, anemia, and preterm birth.

📋While schooling, social support, and infant care are important, physiological needs take top priority according to Maslow's hierarchy.

🩺Assessment of nutrition allows for early interventions that can prevent complications and promote a healthy pregnancy.

📌Core Message

In adolescent pregnancy, assessing nutritional status is the priority to support healthy fetal and maternal outcomes.

1 :
A nurse is providing teaching about immunizations to a client is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 :
A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 :
A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 :
A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 :
A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 :
A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take? (Select all that apply,)

9 :
A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 :
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority

1 : A nurse is providing teaching about immunizations to a client is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 : A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 : A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 : A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 : A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 : A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 : A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 : A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take? (Select all that apply,)

9 : A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 : A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority

1 :
A nurse is providing teaching about immunizations to a client is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 :
A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 :
A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 :
A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 :
A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 :
A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take? (Select all that apply,)

9 :
A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 :
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority