a nurse is preparing to administer a pneumococcal vaccine which of the following should the nurse verify
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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A nurse is preparing to administer a pneumococcal vaccine. Which of the following should the nurse verify?

Correct answer: C

Rationale: The correct answer is C: Client's vaccination history. Before administering a pneumococcal vaccine, the nurse should verify the client's vaccination history to ensure they are due for the vaccine. Verifying the vaccination history helps prevent unnecessary vaccinations and ensures that the client receives the appropriate immunization at the right time. Choices A, B, and D are not directly related to the administration of the pneumococcal vaccine. Checking for allergies to eggs may be important for other vaccines, but it is not specifically relevant to pneumococcal vaccination. The client's current medications and blood pressure are important for general health assessment but are not directly related to verifying the need for a pneumococcal vaccine.

2. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

3. A community nurse is instructing a group of high school students about the transmission of hepatitis A. Which mode of transmission should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C: Fecal-oral. Hepatitis A is primarily transmitted through the fecal-oral route, often from consuming contaminated food or water. Choice A, sexual contact, is not a typical mode of transmission for hepatitis A. Choice B, airborne droplets, is more characteristic of diseases like influenza or tuberculosis. Choice D, bloodborne transmission, is more relevant to hepatitis B and C, not hepatitis A.

4. A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises strengthen bones and help prevent fractures, which is crucial for clients with osteoporosis. Choices B, C, and D are incorrect. Avoiding crossing the legs beyond the midline and avoiding sitting in one position for prolonged periods are general recommendations for preventing musculoskeletal issues but are not specific to osteoporosis. Splinting the affected area is not a standard practice for managing osteoporosis and preventing fractures.

5. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.

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