Prep U/ Qs - Chapter 18: Vaccines and Sera

The parents of an infant are skeptical of immunizing their child, stating, "I've heard a lot about the risks of autism, and I'm not comfortable with increasing that risk." What is the nurse's best response?

"Could we talk about some of the risks that you heard about?" Explanation: The nurse should take an approach that is respectful and which fosters further dialogue without dismissing or downplaying the parents' concerns.

The parents of a two month-old infant have brought their child in to the clinic for the first scheduled immunizations. The parents appear anxious and the child's father says, "We keep hearing about the link between vaccinations and autism. Is there a risk that it could happen to our child?"

"There's been shown to be no genuine link between children receiving vaccinations and developing autism." Explanation: The parent's question specifically focuses on a putative link between vaccines and autism. It has been shown that there is no link so the nurse should provide this information to the client. The statement about not believing everything you hear could be construed as condescending. The risks of autism as a direct result of vaccinations are not low; instead, they are absent. The nurse's general statement about the safety of vaccines does not address the client's specific question.

The nurse is working with the parents of an infant and has initiated a dialogue about immunizations. The infant's parent states, "We're not comfortable with immunizations because of the safety issue." What is the nurse's best response?

"What are some of the safety risks that most concern you?" Explanation: The nurse should attempt the therapeutically engage with the clients' concerns in an attempt to have a productive dialogue. The nurse should avoid being condescending or confrontational. Categorical statements about the safety of immunizations may be true, but are likely to be met with resistance from parents who are reluctant.

The nurse is preparing to administer a dose of the human papillomavirus vaccine to a middle school student. What assessment question should the nurse prioritize when interacting with the student?

"What's your understanding of why you're getting this vaccination?" Explanation: The nurse cannot make the assumption that the client knows about the rationale for the vaccination. The client may know nothing about HPV or its relationship to her future cancer risk. This assessment question can be used to introduce client teaching. A middle school student is unlikely to know whether her parents or caregivers have ensured that her immunizations match the recommended schedule. The HPV vaccine does not require a booster and minimal - if any - side effects are anticipated.

A mother brings her 18-month-old into the clinic for a well-baby check-up. A nurse will administer measles, mumps, and rubella vaccine (MMR) to the 18-month-old. What dosage will the nurse administer?

0.5 mL Explanation: The nurse will administer 0.5 mL. This is the recommended dose for adults and children older than 15 months of age.

The client has been on a systemic corticosteroid for the last 3 weeks. How long should the client wait before receiving a live virus vaccine?

3 months Explanation: Clients who have been on a systemic corticosteroid longer than 2 weeks should wait 3 months before receiving a live virus vaccine.

A 60-year-old male client received a dose of pneumococcal vaccine during a health care provider's visit. What would the nurse recommend?

A second dose when he turns 65 Explanation: A second dose of pneumococcal vaccine may be given at age 65 years if the first dose was given 5 years previously.

What immunizations are recommended for older adults? (Select all that apply.)

A tetanus-diphtheria (Td) booster every 10 years An annual influenza vaccine A one-time administration of pneumococcal vaccine at 65 years of age Explanation: Recommended immunizations for older adults have usually consisted of a tetanus- diphtheria (Td) booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age. Rotavirus vaccine is recommended for infants.

Which statements best indicates the client understands recommended vaccines following the 65th birthday?

A tetanus-diphtheria booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age Explanation: Recommended immunizations for older adults have usually consisted of a tetanus-diphtheria (Td) booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age. A second dose of pneumococcal vaccine may be given at 65 years if the first dose was given 5 years previously.

A health care worker has received an annual influenza vaccination and has remained at the clinic after administration so that the nurse may observe for adverse reactions. The worker reports pain at the site of IM injection. What should the nurse recommend?

Acetaminophen Explanation: Most vaccines can cause fever and soreness at the site of injection. Acetaminophen can be taken two to three times daily for 24 to 48 hours if needed to decrease fever and discomfort. Aspirin and heat are not explicitly recommended; opioids are not necessary.

A hospitalized client is about to receive immunological therapy and asks the nurse to explain the difference between passive and active immunity. In order to provide complete information, the nurse knows to include which information during the teaching session?

Active immunity occurs when a client receives a killed or weakened antigen that stimulates antibodies. These antibodies fight the antigen (for example, chickenpox vaccine). Explanation: Active immunity occurs when a client receives a killed or weakened antigen that stimulates antibodies. These antibodies fight the antigen (for example, chickenpox vaccine). Passive immunity occurs when immune globulin or antivenins are given to provide the person with ready-made antibodies from another human or animal. Cipro is an antibiotic, not an immunologic agent.

A client has presented to the emergency department with a puncture wound suffered a few hours ago while demolishing an old house. The nurse's assessment reveals that the client is not in acute distress. The client's immunization status is unknown. What intervention should the nurse prioritize?

Administering tetanus immune globulin as prescribed Explanation: Puncture wounds are a common source of tetanus infection and the administration of tetanus immune globulin is recommended if the client's immunizations are out of date or unknown. Cytomegalovirus immune globulin is administered to transplant recipients. The client would benefit from education, but this intervention is not time dependent or an immediate priority. The client's injury is recent, so there would not yet be signs of infection.

Which is an example of naturally acquired active immunity? (Select all that apply.)

An individual who is exposed to chickenpox for the first time and has no immunity to the disease. An individual who is exposed to pertussis for the first time and has no immunity to the disease. Explanation: An individual who is exposed to chickenpox or pertussis for the first time and has no immunity to the disease.

A local community group has asked a nurse to speak to them about biological weapons and measures that can be taken. When preparing for the presentation, what immunizations would the nurse mention? (Select all that apply.)

Anthrax Smallpox Botulism Explanation: Vaccines, immunizations, and antitoxins are available for anthrax, smallpox, and botulism. Plague and tularemia do not have immunizations available at this time but exposed clients can be treated with antibiotics.

The administration of immunizations to a client is a form of what type of immunity?

Artificial active immunity Explanation: Immunizations are a form of artificial active immunity.

The nurse is preparing to administer a client's prescribed dose of immune sera. How should the nurse describe this treatment to the client?

Bacterial antibodies in serum Explanation: Immune sera refer to sera that contain antibodies to specific bacteria or viruses. A viral protein coat, weakened bacterial cell membrane, and chemically weakened actual virus can be components of an immunization.

Antivenins are used for passive, transient protection from which bites? (Select all that apply.)

Black widow Rattlesnake Copperhead Explanation: Antivenins are used for passive, transient protection from the toxic effects of bites by black widows, rattlesnakes, copperheads, cottonmouth, and coral snakes.

A school nurse at a large high school is attempting to determine correct vaccine guidelines. What is the best source for current recommendations?

Centers for Disease Control and Prevention Explanation: Recommendations regarding immunizations change periodically as additional information and new immunizing agents become available. Consequently, health care providers need to update their knowledge at least annually. The best source of information for current recommendations is the Centers for Disease Control and Prevention.

It is important for the nurse to stay current with the recommendations for immunizations. Which source is most accurate regarding immunization guidelines?

Centers for Disease Control and Prevention Explanation: The best source of information for current recommendations is the Centers for Disease Control and Prevention.

A nurse should warn a client about which adverse reactions that can occur after the administration of influenza vaccine ? (Select all that apply.)

Chills Fever Lethargy Muscle aches Explanation: Adverse reactions from the administration of vaccines or toxoids are usually mild and include chills, fever, muscle aches and pains, rash, and lethargy.

A group of students are role-playing scenarios involving biological weapon exposure. Which medication would the students identify as using for a client with cutaneous anthrax?

Ciprofloxacin Explanation: For cutaneous anthrax, ciprofloxacin or doxycycline would be used. Ribavirin would be used for hemorrhagic fever; streptomycin or gentamicin would be used for tularemia.

A client is scheduled to receive an immunization. In which client may the administration of a live vaccine be contraindicated?

Client taking steroid therapy Explanation: Clients receiving a systemic corticosteroid in high doses (e.g., prednisone 20 mg or equivalent daily) or for longer than 2 weeks should wait at least 3 months before receiving a live-virus vaccine. No evidence supports withholding immunizations related to renal insufficiency or hepatic failure. Clients over the age of 65 should receive immunizations as needed to protect from infectious disease.

A nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization?

Epinephrine Explanation: The administration of vaccines for immunization possesses the risk of an allergic reaction and anaphylaxis. The nurse should have aqueous epinephrine available in the event of an anaphylactic reaction. The administration of diphenhydramine or hydroxyzine will reduce the allergic reaction but will not be effective in the event of anaphylaxis. Physostigmine is not administered.

A nurse is working at a free vaccination clinic today and expects to give vaccinations to more than one hundred children. Which item is most important to have available?

Epinephrine pen Explanation: Health care providers who are administering vaccines should have aqueous epinephrine 1:1000 readily available to allow immediate treatment of any allergic reaction.

A client who was bitten by a pit viper is to receive antivenin. What is the nurse's best action?

Establish IV access Explanation: Antivenin given to neutralize the venom of a pit viper is administered intravenously.

An adult client received the annual influenza vaccine yesterday afternoon and has now presented back to the clinic reporting malaise. The client's oral temperature is 37.4°C (99.3°F). What is the nurse's best action?

Explain that vaccines often cause a mild immune response and have the client self-monitor Explanation: Vaccines often cause symptoms such as fever, malaise, chills or agitation due to their stimulation of the immune system and the inflammatory process. However, this does not mean the client has an active influenza infection. Anaphylaxis would occur much earlier and with more significant signs and symptoms. Monitoring at the clinic would consequently not be necessary. The client's temperature does not constitute a fever.

Serum sickness results from the overuse of vaccines.

False Explanation: Serum sickness occurs when a host with circulating injected antibodies responds by producing its own antibodies to those injected.

The perinatal nurse recognizes that what vaccine can be safely given to a neonate?

Hepatitis B Explanation: Hepatitis B is the only common vaccine that can be given to neonates.

A nurse is receiving post-exposure prophylaxis for hepatitis B. What would the nurse most likely receive?

Immune globulin Explanation: Hepatitis B immune globulin would be used for post-exposure prophylaxis for hepatitis B. This vaccine would be used to prevent herpes zoster (shingles) in persons over the age of 60 years. Antivenin (crotalidae) would be used to neutralize the venom of pit vipers, rattlesnakes, and copperheads. BCG vaccine would be used to prevent tuberculosis in those with a high risk for exposure.

A group of nursing students are presenting information on the hepatitis B vaccine. What would the students prepare to tell others about the recommended population?

Infants and people at high risk for contracting the disease Explanation: As recommended by the World Health Organization and the CDC, the hepatitis B vaccine should be given to infants and should be given to all children under the age of 18/19 that have not been previously recommended. The vaccine is also recommended in certain high-risk populations among adults. While this population includes children under the age of 15, the vaccine is recommended for all children under the age of 18 or 19. There are not indications to receive the vaccine for people with diabetes or renal disease or all people over the age of 65.

When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration?

It is administered at 12 to 15 months. Explanation: Measles, mumps, and rubella immunization is administered initially at 12 to 15 months of age. The vaccine is not administered under the age of 1 year.

A young mother asks the clinic nurse about the "chickenpox" vaccine. The mother states that she and her husband have both had chickenpox, but that she wants to protect her child if she can. What should the nurse tell the mother about the recommendation for the chickenpox vaccine?

It is recommended for all children who have not been exposed to the varicella virus. Explanation: Measles, mumps, rubella, varicella virus vaccine 0.5 mL Sub-Q. Simultaneous immunization against measles, mumps, rubella, and varicella in children aged 12 months to 12 years.

A nursing instructor is discussing the intended populations for various vaccines. Which groups might the instructor mention when discussing the hepatitis B vaccine?

Paramedics and emergency medical technicians Explanation: Pre-exposure immunization against hepatitis B is recommended for people at high risk for exposure to the disease. This can include health care workers (e.g., paramedics and EMTs); patients with cancer, organ transplants, hemodialysis, immunosuppression drug therapy, or multiple infusions of blood products; sexually active gay and bisexual males; IV drug users; household contacts of HBV carriers; and residents and staff of institutions for people with intellectual disability.

When discussing vaccines in class, a student asks the instructor what an antitoxin is? What is an example of an antitoxin?

Passive immunity Explanation: An antitoxin is an example of passive immunity. Antitoxins contain antibodies to very specific toxins. The antibodies are injected into the system and react with invading pathogens. Active immunity occurs when the body recognizes a foreign protein and begins producing antibodies to react with that specific protein or antigen. Vaccines are immunizations containing weakened or altered protein antigens that stimulate formation of antibodies against a specific disease. They are used to promote active immunity. Toxoids are vaccines that are made from the toxins produced by the microorganisms.

For what group of adults is pre-exposure immunization against hepatitis B recommended?

People who receive hemodialysis Explanation: Pre-exposure immunization against hepatitis B is recommended for high-risk groups. These may include health care workers; clients with cancer, organ transplants, hemodialysis, immunosuppression drug therapy, or multiple infusions of blood products;sexually active gay and bisexual males; IV drug users; household contacts of HBV carriers; and residents and staff of institutions for people with intellectual disability.

A nurse is participating in an influenza vaccination clinic on a college campus. What action will best prepare the nurse for this role?

Review the procedure for intramuscular injection Explanation: Influenza vaccinations are given by the IM route. The nurse must monitor for adverse effects, but it is unnecessary to teach each client the details of serum sickness. Clients do not need to know their blood types.

A child who is recovering from a chickenpox infection is given aspirin for the fever. Which condition develops following the simultaneous administration of salicylates and the varicella vaccine?

Reye syndrome Explanation: When salicylates are administered along with the varicella vaccine, there is an increased risk of development of Reye syndrome. It is often associated with children who are given aspirin-containing medicines while they have chickenpox (varicella). Lymphoma, angioneurotic edema, and acute renal failure do not develop with the simultaneous administration of salicylates and the varicella vaccine.

A client develops fever and arthralgia 4 days after the administration of tetanus toxoid. What reaction to the vaccine is this?

Serum sickness Explanation: Serum sickness presents several days after the administration of a vaccine with symptoms of urticaria, fever, arthralgia, and enlarged lymph nodes. The presence of fever and arthralgia after the administration of an immunization is not noted as an infectious process, anaphylaxis, or distress syndrome.

A 65-year-old male client lives in a long-term care facility. The infection control nurse identifies a cluster of clients on the unit diagnosed with shingles. What would the nurse expect the client's prescriber to order?

Shingles vaccine Explanation: Vaccine to prevent shingles is available for adults aged 60 years and older.

A client is scheduled to receive immunization with a live vaccine. The nurse would hold the vaccine and contact the health care provider when noticing what information in the client record?

Steroid therapy Explanation: A risk of producing disease exists with live vaccines, especially in people with impaired immune function. Clients who are on steroid therapy should not receive live vaccines due to impaired immune function. No evidence supports withholding immunizations related to renal insufficiency or hepatic failure. Clients over the age of 65 should receive immunizations as needed to protect from infectious disease.

What would the nurse identify as a vaccine that is a toxoid?

Tetanus Explanation: The vaccine for tetanus is a toxoid. The vaccines for haemophilus influenza B and pneumococcal polyvalent are bacterial vaccines. Hepatitis A is a viral vaccine.

Middle aged adults and health care workers should receive which immunizations?

Tetanus-diphtheria-pertussis; hepatitis B vaccine once and influenza vaccine annually Explanation: Middle-aged adults should maintain immunizations against tetanus-diphtheria-pertussis; high-risk groups (e.g., those with chronic illness) and health care providers should receive hepatitis B vaccine once (if not previously taken) and influenza vaccine annually at 50 years of age and older.

A client has come to the clinic requesting a hepatitis A and B vaccination before leaving on a tropical vacation. After assessing the client, the nurse should prioritize what finding to communicate to the provider?

The client takes corticosteroids to treat rheumatoid arthritis Explanation: Corticosteroids decrease the normal immune response and could interfere with the intended stimulation of B cells. Recent influenza vaccination does not contraindicate the hepatitis vaccine, nor does type 2 diabetes. Occasional marijuana use would not contraindicate a hepatitis vaccination.

After teaching a group of students about the standard childhood immunizations given today, the instructor determines that the students need additional teaching when they identify which as a common disease for which immunizations are given?

Tuberculosis Explanation: Immunization for tuberculosis occurs worldwide, but it is not routinely used in the United States.

A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster?

Zoster vaccine Explanation: Zoster vaccine is administered to adults 60 years and older to prevent herpes zoster (shingles). The Haemophilus influenzae type B is not administered to prevent herpes zoster. HPV and pneumococcal vaccine do not address the risk factors for shingles.

The nurse is educating an older adult client on routine vaccines. Which statement best describes the recommended vaccination schedule for an older adult client?

a tetanus-diphtheria booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age Explanation: Recommended immunizations for older adults have usually consisted of a tetanus-diphtheria (Td) booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age. A second dose of pneumococcal vaccine may be given at 65 years if the first dose was given 5 years previously. None of the other options present accurate information concerning currently recommended vaccination scheduling for older clients.

The nurse is assessing a 6-month-old infant prior to scheduled immunizations. What finding would the nurse immediately recognize as a reason to reschedule administration?

low-grade fever Explanation: Contraindications to most vaccines and toxoids include acute febrile illness. Fussy crying, loose stools, and poor feeding would warrant further assessment but may not contraindicate the administration of a vaccine.

A nurse prepares to administer antithymocyte immune globulin. The nurse understands that this is used to:

treat acute renal transplant rejection. Explanation: Antithymocyte immune globulin is used to treat acute renal transplant rejection. The varicella virus vaccine would be used to prevent varicella (chickenpox). Hepatitis B immune globulin would be used for post exposure prophylaxis for hepatitis B. Respiratory syncytial virus (RSV) immune globulin would be used to prevent RSV in children younger than 2 years of age with bronchopulmonary dysplasia or premature birth.