A nurse is assessing a client who is experiencing profuse vomiting.

Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.

The client appears restless and anxious and states that he thinks he is dying.

Which of the following actions should the nurse take first?

Choice A rationale

The herpes zoster vaccine, also known as the shingles vaccine, is specifically recommended for older adults. The incidence and severity of shingles, which is caused by the reactivation of the varicella-zoster virus, increase significantly with age, particularly after 50 years. The vaccine works by boosting the immune response to the virus, thereby reducing the risk of developing shingles and the associated long-term neuropathic pain.

Choice B rationale

The human papillomavirus (HPV) vaccine is recommended for individuals up to age 26, with a primary target age of 11 or 12. It is not typically recommended for older adults because most have already been exposed to the virus, and the vaccine is most effective before sexual activity begins. The immune response in older adults is also less robust than in younger individuals, making the vaccine less effective in this population.

Choice C rationale

The rotavirus vaccine is recommended for infants and young children, usually in a series of doses starting at 2 months of age. Rotavirus is a common cause of severe diarrhea in infants and young children, but it does not pose a significant health threat to older adults. The vaccine is not indicated for older adults because they have usually developed immunity from previous exposures to the virus.

Choice D rationale

Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is primarily given to infants and young children in a series of doses. For older adults, the Tdap or Td booster is recommended. The Tdap vaccine provides protection against tetanus, diphtheria, and pertussis, which is important for older adults as their immunity wanes over time. However, the DTaP formulation is not the one typically recommended for this age group. .

Choice A rationale

Documenting a summary of data at the change of shift is a critical component of interprofessional communication, ensuring continuity of care. However, initial charting should be done promptly after data collection to maintain accuracy and prevent errors. Delaying documentation can lead to misinterpretation or omission of crucial information regarding the client's condition and needs. This practice ensures all members of the healthcare team are informed.

Choice B rationale

Noting whether a client has a living will is a fundamental ethical and legal obligation. This advance directive provides a written expression of a client’s wishes regarding medical treatment, which must be respected and documented in the medical record. It guides the healthcare team's decisions and ensures that the client's autonomy and right to self-determination are upheld.

Choice C rationale

Evaluation is the final step of the nursing process, following assessment, diagnosis, planning, and implementation. The nurse must first collect objective and subjective data, then analyze it before determining an appropriate plan of care. Beginning with an evaluation would bypass the essential steps of data collection and analysis, leading to an inaccurate or unsafe plan of care.

Choice D rationale

While assistive personnel can collect vital signs, the nurse is professionally and legally responsible for the data's accuracy and interpretation. The nurse must verify the data, analyze trends, and ensure it is documented accurately and promptly. The nurse is ultimately accountable for any actions taken based on this data, making proper documentation and validation essential.