A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client.
The client tells the nurse, "I no longer want to receive this vaccine."

Which of the following responses should the nurse make?

"If I were you, I would get the vaccine to keep my family safe.”

"Influenza can be very serious to anyone who does not receive the vaccine.”

"The influenza vaccine is strongly encouraged, but I understand you would like to decline right now.”

"The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form.”

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale:

This response is not appropriate because it is judgmental and may make the client feel defensive.
It is important for the nurse to respect the client's right to make their own decisions about their health care.
Telling the client what they should do can undermine their autonomy and potentially damage the nurse-client relationship.
It's crucial for the nurse to remain objective and avoid imposing their personal opinions or beliefs onto the client.

Choice B rationale:

This response is also not appropriate because it is using scare tactics to try to persuade the client to get the vaccine.
This approach can be counterproductive and may further alienate the client.
It's important to provide accurate information about the risks and benefits of the vaccine in a neutral and non-threatening manner.

Choice C rationale:

This is the most appropriate response because it acknowledges the client's right to refuse the vaccine while still encouraging them to get it.
It also demonstrates respect for the client's autonomy and validates their feelings.
This approach is more likely to foster a positive nurse-client relationship and keep the door open for future discussions about vaccination.

Choice D rationale:

This response is not accurate because the influenza vaccine is not mandatory for all clients before discharge.
It is important for the nurse to provide accurate information to the client.
Threatening the client with an against medical advice form is not appropriate and may be considered a form of coercion.

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Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale:

Documenting the administration of the medication is crucial for maintaining accurate records and ensuring accountability. However, it is not the first action to take. The priority is to ensure the correct patient receives the correct medication.

Choice B rationale:

Identifying the client using two identifiers is the first and most critical step. This action ensures that the right patient receives the right medication, thereby minimizing the risk of medication errors.

Choice C rationale:

Comparing the amount of medication available to the inventory record is important for maintaining accurate inventory and preventing misuse or theft of controlled substances. However, this is not the first step in the process of administering medication to a patient in pain.

Choice D rationale:

Removing the medication from the medication dispensing cabinet is part of the process, but it should only be done after the patient has been properly identified to avoid any potential errors.

A. Use the Z-track method to administer the medication. B. Grasp skin between thumb and forefinger throughout the injection. C. Aspirate the syringe prior to injecting the heparin. D. Gently massage the site following the injection.

Correct Answer is B

Explanation

When administering heparin subcutaneously, the nurse should grasp the skin between the thumb and forefinger throughout the injection to minimize bleeding following the injection.

Choice A is wrong because Use the Z-track method to administer the medication, is not the correct answer because the Z-track method is a technique used for intramuscular injections, not subcutaneous injections.

Choice C is wrong because Aspirate the syringe prior to injecting the heparin, is not the correct answer because aspiration is not necessary when administering heparin subcutaneously.

Choice D is wrong because Gently massage the site following the injection, is not the correct answer because massaging the injection site can increase the risk of bruising and bleeding.

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A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client. The client tells the nurse, "I no longer want to receive this vaccine." Which of the following responses should the nurse make?

Nursing Test Bank

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A nurse on a medical-surgical unit is preparing to administer an influenza vaccine to a client.
The client tells the nurse, "I no longer want to receive this vaccine."

Which of the following responses should the nurse make?