Nursing Elites

1. A healthcare provider is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?

• A. The possibility of pregnancy within 4 weeks
• B. Client allergy to strawberries
• C. Client history of genital herpes
• D. The possibility of overseas travel in the next month

Correct answer: A

Rationale: The correct answer is A. Pregnancy or the possibility of pregnancy within 4 weeks is a contraindication for receiving the MMR vaccine. Choice B, client allergy to strawberries, is not a contraindication to the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication to the MMR vaccine.

2. A healthcare professional is caring for a client receiving gentamicin therapy. Which of the following client assessments is a priority for the healthcare professional to monitor for an adverse effect of this medication?

• A. Urinary output
• B. Serum glucose
• C. Respiratory rate
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D: Hearing acuity. Gentamicin is known to be ototoxic, which means it can cause damage to the auditory system leading to hearing loss. Monitoring hearing acuity is crucial to detect early signs of hearing impairment. Monitoring urinary output (choice A) is important for assessing kidney function but is not directly related to gentamicin's adverse effects. Monitoring serum glucose (choice B) and respiratory rate (choice C) are not specifically associated with gentamicin therapy.

3. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

4. A nurse is caring for a client who has been prescribed amoxicillin. Which of the following client history findings requires the nurse to clarify the medication prescription?

• A. Hypertension
• B. Peptic ulcer disease
• C. Asthma
• D. Gastroesophageal reflux disease

Correct answer: C

Rationale: The correct answer is C. Clients with a history of asthma should avoid amoxicillin due to potential hypersensitivity reactions. Amoxicillin can trigger asthma exacerbations in some individuals. Hypertension (choice A), peptic ulcer disease (choice B), and gastroesophageal reflux disease (choice D) are not contraindications for amoxicillin use, so they do not require the nurse to clarify the medication prescription in this case.

5. Before administering blood products, which action should be taken?

• A. Assess the client's temperature
• B. Document client response
• C. Prime IV tubing with 0.45% sodium chloride
• D. Administer epinephrine

Correct answer: A

Rationale: Correct answer: Before administering blood products, the client's temperature must be assessed to establish a baseline and monitor for transfusion reactions. Choice B is incorrect because documenting client response should occur after administering the blood products. Choice C is incorrect as priming IV tubing with 0.45% sodium chloride is not directly related to assessing the client before administering blood products. Choice D is incorrect because administering epinephrine is not a routine action before administering blood products.

Similar Questions