Question

A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

Answer 1

Correct Answers:

Inactivated influenza vaccine
Tetanus, diphtheria and acellular pertussis vaccine

Rationale :

🔷 Live vaccines like rubella and varicella are contraindicated because they can cross the placenta and harm the fetus.

🔷 Inactivated influenza vaccine is recommended during pregnancy to prevent complications like pneumonia, which can be severe in pregnant clients.

🔷 Tdap is safe and provides maternal antibodies that protect the newborn against pertussis after birth.

🔷 Pregnancy suppresses the immune system, making immunization with inactivated vaccines essential to reduce maternal morbidity.

🔷 Timing of Tdap is between 27–36 weeks, maximizing neonatal antibody transfer

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Answer 2

Correct Answers:

Place the client on oxygen using a mask
Stop cooling interventions once core body temperature is 39°C (102°F).
Infuse IV fluids.

Rationale :

💎 Heat stroke is a medical emergency, requiring rapid stabilization of airway, breathing, and circulation.

💎 Oxygen support improves cellular oxygenation and prevents hypoxemia due to increased metabolic demand.

💎 Cooling interventions must be stopped at 39°C to avoid rebound hypothermia and shivering.

💎 IV fluids are critical to restore intravascular volume and prevent circulatory collapse.

💎 Antipyretics and benzodiazepines are not effective for true heat stroke, as it is not caused by infection or seizures primarily.

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Answer 3

Correct Answers:

Magazines are stacked neatly on the stairs.

Rationale :

✔️ Stacked items on stairs increase fall risk, especially for clients with mobility issues.

✔️ A hip fracture client is at high risk of severe complications from even minor falls.

✔️ Safe homes require clear pathways, secured flooring, and removal of clutter.

✔️ Stairways should be free of tripping hazards and well-lit to prevent accidents.

✔️ Hip fracture recovery is prolonged; additional falls delay healing and increase morbidity.

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Answer 4

Correct Answers:

Take a hot shower every day.

Rationale :

🟡 Heat therapy (warm showers, heating pads) reduces stiffness and improves joint mobility in osteoarthritis.

🟡 It promotes muscle relaxation and increases blood flow to affected areas.

🟡 Unlike ice, heat is preferred for chronic stiffness, while cold is used for acute inflammation.

🟡 Daily routine use of heat provides consistent pain relief and improved function.

🟡 Teaching emphasizes joint protection and comfort, reducing dependence on medications.

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Answer 5

Correct Answers:

Establish a patent airway.

Rationale :

🔴 Airway patency is always the priority in trauma (ABC framework).

🔴 Nasal bleeding can obstruct the airway and compromise breathing.

🔴 Clients with head trauma are at risk for brain hypoxia, worsening neurological injury if not managed.

🔴 Airway management must be secured before diagnostics like CT scans.

🔴 Applying pressure could be contraindicated if there’s a basilar skull fracture.

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Answer 6

Correct Answers:

Determine if the AP has the skills to perform the test.

Rationale :

🟢 Delegation requires the RN to verify that the AP is competent and trained for the task.

🟢 Safety is maintained by ensuring the AP follows proper technique for accurate glucose results.

🟢 The RN retains accountability and must evaluate task appropriateness.

🟢 Checking competence prevents errors in patient management, especially for diabetes care.

🟢 This follows the “Right person, Right task, Right circumstance, Right communication, Right supervision” principle.

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Answer 7

Correct Answers:

Fentanyl

Rationale :

🌟 Fentanyl is a strong opioid analgesic appropriate for severe, acute pain episodes.

🌟 It provides rapid onset and effective relief when other pain measures are insufficient.

🌟 Non-opioid options like acetaminophen are inadequate for acute severe pain.

🌟 Fentanyl is short-acting, making it suitable for acute episodes rather than long-term control.

🌟 Monitoring for respiratory depression is essential due to potency.

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Answer 8

Correct Answers:

Check gastric residuals every 4 hr.
Maintain the head of the client's bed at a 30degrees angle or higher.
Change the feeding container and tubing every 24 hr.

Rationale :

♦️ Checking gastric residuals every 4 hr prevents aspiration by monitoring tolerance.

♦️ Keeping the head of bed elevated ≥30° reduces risk of aspiration pneumonia.

♦️ Changing container and tubing every 24 hr prevents bacterial contamination and infection.

♦️ X-ray verification is only done once on insertion, not daily.

♦️ Cold formula delays gastric emptying; formula should be room temperature.

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Answer 9

Correct Answers:

“Biofeedback requires concentration to control physiological responses."

Rationale :

✨ Biofeedback teaches clients to use mental control to regulate involuntary body functions like muscle tension and heart rate.

✨ It requires focus and practice, helping reduce migraine frequency and severity.

✨ It enhances self-regulation of stress responses without relying on medications.

✨ Clients learn to recognize early signs of tension and intervene effectively.

✨ Often combined with relaxation techniques for optimal migraine management.

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Answer 10

Correct Answers:

Current nutritional status

Rationale :

⭐ Pregnancy in adolescence increases risk for nutritional deficiencies due to competing needs of maternal growth and fetal development.

⭐ Poor nutrition raises risk for low birth weight, preterm birth, and maternal complications.

⭐ Assessing nutrition guides dietary counseling and supplementation.

⭐ Other factors (school, peers, infant care knowledge) are important but not as urgent as nutrition.

⭐ Early identification prevents long-term maternal and neonatal complications.

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QLexNursing

1 :
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 :
A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 :
A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 :
A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 :
A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 :
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?re

QLexNursing

1 : A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 : A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 : A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 : A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 : A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 : A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 : A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 : A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

9 : A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 : A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?re

1 :
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply.)

2 :
A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take? (Select all that apply.)

3 :
A nurse is performing a home safety assessment on a client who has a hip fracture. Which of the following observations should the nurse identify as a safety hazard?

4 :
A nurse is providing teaching about nonpharmacological pain management to a client who has osteoarthritis. Which of the following instructions should the nurse include in the teaching?

5 :
A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

6 :
A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

7 :
A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

8 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

9 :
A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the following information should the nurse include in the teaching?

10 :
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?re