A nurse is assessing a client for allergies prior to administering the influenza vaccine.
The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine?

- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.

- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.

- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.

- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.

Maintain sterile objects within the line of vision.

• A. Hold hands folded below the waist after donning sterile gloves. This is incorrect because holding hands below the waist can contaminate the gloves with microorganisms from the floor or clothing.
• B. Pick up and pour solutions with the palm of the hand covering bottle labels. This is incorrect because covering bottle labels can obscure important information such as expiration dates or ingredients.
• C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. This is incorrect because the border of the sterile drape is considered contaminated and any sterile item that touches it becomes contaminated as well.
• D. Maintain sterile objects within the line of vision. This is correct because keeping an eye on sterile objects ensures that they are not accidentally touched by nonsterile items or persons.