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 client is being taught about the use of metformin. Which of the following should be included?

Correct answer: A

Rationale: Corrected Rationale: Metformin should be taken with food to minimize gastrointestinal side effects. Choice A is the correct answer as taking metformin with meals can help reduce the likelihood of experiencing gastrointestinal side effects like diarrhea and nausea, which are common side effects of metformin. Choice B is incorrect because metformin actually helps lower blood sugar levels and does not cause hyperglycemia. Choice C is incorrect as metformin is usually taken twice or even three times a day, not just once daily. Choice D is incorrect because metformin is an oral medication, not an injectable one.

3. A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?

Correct answer: B

Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.

4. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?

Correct answer: B

Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.

5. A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?

Correct answer: A

Rationale: Premature ovarian failure should be identified as affecting the client's fertility. It leads to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles, which can impact fertility. Renal calculi, dysmenorrhea, and recurrent urinary tract infections do not directly affect fertility and are not typically associated with infertility assessments. Renal calculi are kidney stones that do not directly relate to reproductive health. Dysmenorrhea is painful menstruation but does not necessarily indicate infertility. Recurrent urinary tract infections primarily affect the urinary system and do not directly impact fertility.

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