a patient is deciding whether they should take the live influenza vaccine nasal spray or the inactivated influenza vaccine shot the nurse reviews the
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. A patient is deciding whether they should take the live influenza vaccine (nasal spray) or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?

Correct answer: D

Rationale: The correct answer is that the patient has young children. Having young children is not a contraindication for the live influenza vaccine unless the children are immunocompromised, which is not mentioned. Choice A, the patient taking long-term corticosteroids, is a contraindication for the live vaccine due to potential immunosuppression. Choice B, the patient not feeling well today, is a general precaution for vaccination and not a contraindication specific to the live influenza vaccine. Choice C, the patient being 55 years old, is not a contraindication for the live vaccine unless there are other specific medical conditions present.

2. Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:

Correct answer: D

Rationale: Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.

3. The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?

Correct answer: A

Rationale: The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.

4. A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?

Correct answer: D

Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.

5. Which of the following factors may alter the level of consciousness in a patient?

Correct answer: D

Rationale: Various factors can lead to altered levels of consciousness in a patient. Alcohol consumption can depress the central nervous system and cause changes in consciousness. Electrolyte imbalances, such as hyponatremia or hypernatremia, can disrupt brain function and affect consciousness. Infections, especially those affecting the brain like encephalitis, can also lead to alterations in consciousness. Therefore, all of the choices provided - Alcohol, Electrolytes, and Infection - can potentially cause changes in the level of consciousness. Remember the acronym AEIOU-TIPPS to recall common causes of decreased level of consciousness, including Alcohol, Electrolytes, and Infection, among others.

Similar Questions

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?
A child presents to the emergency department with colicky abdominal pain in the lower right quadrant. What disorder is suspected based on these symptoms?
While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses