a nurse is preparing to administer a pneumococcal 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 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 caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

Correct answer: A

Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.

3. A healthcare professional is caring for a client receiving potassium-sparing diuretics. Which of the following should the healthcare professional monitor?

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving potassium-sparing diuretics, the healthcare professional should monitor for hyperkalemia. Potassium-sparing diuretics can cause potassium retention, leading to elevated potassium levels in the blood. Monitoring potassium levels is crucial to prevent hyperkalemia-related complications such as cardiac arrhythmias. Choices A, C, and D are incorrect because potassium-sparing diuretics typically do not cause hypokalemia, hypoglycemia, or hyponatremia.

4. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?

Correct answer: A

Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.

5. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?

Correct answer: A

Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.

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