Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is administering the inactivated influenza vaccine to a group of clients at a health clinic.
The nurse should recognize that which of the following conditions is a contraindication for this vaccine?
A. Pregnancy.
Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.
B. Immunosuppression.
Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.
C. Allergy to gelatin.
Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.
D. Moderate illness with fever.
Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
The correct answer is choice C. Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.
Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.
Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.
Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.
Similar Questions
A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?
A. Sepsis.
Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.
B. Tachypnea.
Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.
C. Bleeding.
The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.
D. Jaundice.
Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.
Full Explanation
The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.
Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.
Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.
Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.
A nurse is collecting data from a client who is recovering from a recent stroke.
Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?
A. Coughing while eating.
Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.
B. Fine motor tremors.
Choice B is wrong because fine motor tremors are not related to speech or language problems. They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.
C. Facial flushing.
Choice C is wrong because facial flushing is not related to speech or language problems. It may be caused by high blood pressure, fever, anxiety or other conditions.
D. Urinary incontinence.
Choice D is wrong because urinary incontinence is not related to speech or language problems. It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.
Full Explanation
Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.
Choice B is wrong because fine motor tremors are not related to speech or language problems.
They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.
Choice C is wrong because facial flushing is not related to speech or language problems.
It may be caused by high blood pressure, fever, anxiety or other conditions.
Choice D is wrong because urinary incontinence is not related to speech or language problems.
It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.
A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?
A. Medical diagnosis.
Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.
B. Number of visitors.
Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.
C. Routine care.
A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.
D. Expected laboratory results.
Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.
Full Explanation
A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.
Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.
Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.
Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.