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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Set up the sterile field 5 cm (2 in) below waist level: Sterile fields must be at or above waist level to maintain sterility. Anything below the waist is considered contaminated because it is out of the nurse’s visual field and control.
B. Place the cap from the solution sterile side up on a clean surface: The inside of the cap must face up to avoid contamination. Placing it on a clean surface with the sterile side up preserves sterility for recapping the solution if needed.
C. Open the outermost flap of the sterile kit toward the body: The first flap should be opened away from the body to prevent reaching over the sterile field, which increases the risk of contamination.
D. Place the sterile dressing within 1.25 cm (0.5 in) of the ledge of the sterile field: Items must be placed at least 2.5 cm (1 in) from the edge of the sterile field. The outer 1 inch is considered non-sterile and any item placed within this margin is no longer sterile.
Correct Answer is ["B","C","E"]
Explanation
Rationale for Correct Findings:
- Productive cough: In a client with COPD and recent MI, this may signal infection or fluid overload, especially if paired with fever, dyspnea, and hypoxia. Immediate assessment is needed to rule out pneumonia or heart failure.
- Shortness of breath and chest pain with ambulation: This raises concern for myocardial ischemia, reinfarction, or worsening heart function. Chest pain with minimal exertion post-MI demands prompt evaluation and possible ECG and oxygen therapy.
- Anxiety and fear of dying: Sudden intense fear may indicate worsening hypoxia, cardiac distress, or even be a prodrome to another MI. It should not be dismissed as purely psychological, especially in the context of other concerning symptoms.
Rationale for Incorrect Findings:
- Pain rated 3/10: A mild pain score suggests the discomfort is currently manageable. While chest pain after MI is always important, this level does not in itself indicate an emergency unless it worsens or is unrelieved.
- Oriented to room: Being alert and oriented indicates preserved cognition and neurologic stability. No immediate follow-up is needed based on this observation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.