a nurse is preparing to administer an influenza vaccine to an adult client which of the following is a contraindication
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A healthcare provider is preparing to administer an influenza vaccine to an adult client. Which of the following is a contraindication?

Correct answer: B

Rationale: The correct answer is B: Client is allergic to eggs. The influenza vaccine is contraindicated in individuals with an allergy to eggs because some influenza vaccines are produced using egg-based processes. Choices A, C, and D are not contraindications for administering the influenza vaccine. A low-grade fever, recent surgery, and corticosteroid therapy are not contraindications for receiving the influenza vaccine.

2. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

3. Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?

Correct answer: A

Rationale: Placing the newborn under a radiant heat warmer is used to prevent cold stress. Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature, potentially resulting in hypoglycemia and metabolic acidosis if not addressed. The radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications. Choices B, C, and D are incorrect because the primary purpose of using a radiant warmer in this scenario is to prevent cold stress specifically, not hyperthermia, dehydration, or hypoxia.

4. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

5. A client is reviewing information about advance directives with a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because having a living will indicates that the client understands and has documented their wishes regarding medical treatment when they are unable to make decisions. Choice A is incorrect because while it's true that clients can change their minds about advance directives, it doesn't specifically indicate an understanding of the teaching provided. Choice C is important but doesn't directly show if the client understands advance directives. Choice D is incorrect because it dismisses the importance of advance directives, indicating a lack of understanding.

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