a nurse is preparing to administer a flu vaccine which of the following should the nurse verify
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A healthcare professional is preparing to administer a flu vaccine. Which of the following should the healthcare professional verify?

Correct answer: C

Rationale: The healthcare professional should verify the client's vaccination history to ensure they are due for the flu vaccine. Verifying the client's age (choice A) is important for other vaccines but not specifically for the flu vaccine. While allergy to eggs (choice B) is relevant as the flu vaccine is traditionally produced in eggs, it is not the top priority for verification. The client's weight (choice D) is not directly related to the administration of the flu vaccine.

2. A client with chronic kidney disease is about to start hemodialysis. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is to instruct the client to reduce potassium intake. Clients with chronic kidney disease should limit potassium intake to prevent hyperkalemia, as the kidneys may struggle to remove excess potassium. Increasing protein intake between dialysis sessions (Choice A) is not recommended as it can increase urea production, adding to the workload of the kidneys. Avoiding iron supplements (Choice C) is not necessary unless iron levels are high. Expecting weight gain after each dialysis session (Choice D) is incorrect as patients typically experience weight loss due to fluid removal during dialysis.

3. Which of the following are contraindications to salicylic acid therapy?

Correct answer: A

Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.

4. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.

5. A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client's membranes have ruptured?

Correct answer: C

Rationale: The correct answer is the Fern test. The Fern test is specifically used to confirm the rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid. The Nonstress test (Choice A) is used to monitor fetal heart rate and movement, not to confirm ruptured membranes. The Biophysical profile (Choice B) is a prenatal ultrasound evaluation to assess fetal well-being, not to confirm ruptured membranes. Amniocentesis (Choice D) involves the aspiration of amniotic fluid for various diagnostic purposes, not specifically to confirm ruptured membranes.

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