A nurse is assessing a client prior to administering the influenza vaccine. The nurse should assess if the client has an allergy to which of the following foods?

Gelatin

Shellfish

Egg

Milk

Answer and Explanation

The Correct Answer is C

Rationale:

A. Gelatin: Gelatin allergies are more relevant when assessing for risk with certain vaccines like MMR or varicella, which may contain gelatin as a stabilizer. It is not a primary concern with most influenza vaccines.

B. Shellfish: Shellfish allergies are associated with reactions to iodine-based contrast, not vaccines. They do not impact the safety of receiving the influenza vaccine.

C. Egg: Many influenza vaccines are manufactured using egg-based processes, which can leave residual egg protein. Although most clients with egg allergies can now safely receive the vaccine, this allergy is still important to assess before administration.

D. Milk: Milk allergies are not linked to influenza vaccines and do not affect vaccine safety. There is no milk protein used in the manufacturing of flu vaccines.

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Correct Answer is D

Explanation

Rationale:

A. Ritualistic behavior: Ritualistic or compulsive behaviors are most commonly associated with obsessive-compulsive personality disorder or obsessive-compulsive disorder, not narcissistic personality disorder.

B. Suspicious of others: Suspiciousness and distrust are hallmark features of paranoid personality disorder. While individuals with narcissistic traits may be sensitive to criticism, they are not generally suspicious in a paranoid sense.

C. Exhibits separation anxiety: Separation anxiety and fear of being alone are typically seen in dependent personality disorder and sometimes borderline personality disorder, not narcissistic personality disorder.

D. Preoccupied with aging: Clients with narcissistic personality disorder are often highly concerned with maintaining a youthful and admired image. They may fear aging due to its association with loss of beauty, status, or power, making this the expected finding.

A. Attach a single-line administration set B. Prime the tubing with 0.9% sodium chloride. C. Use an IV catheter that is at least 24-gauge. D. Use tubing that does not have a filter in the drip chamber.

Correct Answer is B

Explanation

Rationale:

A. Attach a single-line administration set: A blood transfusion requires a Y-type tubing with a filter and two lines—one for the blood and one for normal saline—to allow flushing and compatibility. A single-line set is inadequate.

B. Prime the tubing with 0.9% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime blood tubing, as it is compatible with blood products and prevents clotting or hemolysis. Dextrose or other solutions can cause cell lysis.

C. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for routine blood transfusions. A larger bore, such as 18- to 20-gauge, is recommended to reduce the risk of hemolysis and allow adequate flow.

D. Use tubing that does not have a filter in the drip chamber: Blood transfusion sets must include a filter (usually 170–260 microns) to trap clots and debris. Using tubing without a filter increases the risk of transfusion reactions.

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A nurse is assessing a client prior to administering the influenza vaccine. The nurse should assess if the client has an allergy to which of the following foods?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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