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Questions 164

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Question 1 of 5

A 79-year-old client asks the nurse if she needs any shots. She reports having had 'all the usual shots when I was younger.' Which immunization is most important for this person to receive?

Correct Answer: C

Rationale: Pneumovax is critical for adults over 65 to prevent pneumococcal pneumonia, a significant risk in the elderly.

Question 2 of 5

The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:

Correct Answer: B

Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.

Question 3 of 5

A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?

Correct Answer: B

Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.

Question 4 of 5

All of the following need to be done. Which should the nurse do first?

Correct Answer: A

Rationale: Pain management for a client post-surgery today is a priority to promote comfort and recovery. Dressing changes, bed baths, and preoperative enemas are less urgent.

Question 5 of 5

The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client?

Correct Answer: B

Rationale: Keeping a diary of activities and symptoms correlates events with cardiac readings, aiding diagnosis. Transmitting readings is not client responsibility, and Holter monitors are typically worn continuously, including during bathing.

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