Chapter 12: Drug Therapy: Immunizations

A 1-year-old child will receive a scheduled MMR vaccination shortly. The nurse should teach the child's parents that the child may develop what possible adverse effect related to the administration of this medication? A. Cough and fever B. Pallor and listlessness C. Serum sickness D. Nausea and vomiting

ANS: A Rationale: Adverse effects associated with MMR vaccine include fever and cough. Nausea and vomiting, pallor and listlessness, and serum sickness are not among the noted adverse effects of the MMR vaccine.

A primiparous woman tells the nurse that she and her partner are highly reluctant to have their infant vaccinated, stating, "We've read that vaccines can potentially cause a lot of harm, so we're not sure we want to take that risk." How should the nurse respond to this family's concerns? A. "Vaccinations are not without some risks, but these are far exceeded by the potential benefits." B. "The potential risks of vaccinations have been investigated and determined to be nonexistent." C. "Unfortunately, state laws mandate that your child receive the full schedule of vaccines." D. "Vaccines indeed cause several serious adverse effects, but these are usually treated at the site where your child receives the vaccination."

ANS: A Rationale: Mild reactions to vaccinations are common, but serious reactions are rare. Consequently, the benefits of vaccinations exceed the risks. Parental choice is still respected in most instances.

A client is to be administered an immunization. The serum contains aluminum phosphate. What route is the most appropriate to administer this immunization? A. Intramuscularly B. Subcutaneously C. Intravenously D. Orally

ANS: A Rationale: Products containing aluminum should be given intramuscularly only because they cannot be given intravenously, and greater tissue irritation occurs with subcutaneous injections. Immunizations containing aluminum are not administered orally.

A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster? A. Zoster vaccine B. Haemophilus influenzae type B vaccine C. Human papillomavirus (HPV) D. Pneumococcal polyvalent

ANS: A Rationale: 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 college health nurse is providing health education for freshmen. Which piece of information about immunizations is applicable to individuals of this group? A. The oral polio should be updated. B. The yearly administration of flu vaccine is recommended. C. The tetanus toxoid must be within 2 years. D. The administration of hepatitis A vaccine is mandatory.

ANS: B Rationale: An annual flu vaccine is recommended for all adults. The administration of oral polio will not need to be updated in this population. The administration of tetanus toxoid should be every 10 years. HAV vaccination is not mandatory.

An older adult client is seen in the emergency department for a laceration sustained on broken glass. The nurse assesses the client for the last tetanus toxoid received. How often should the client be administered a tetanus toxoid? A. Every year B. Every 10 years C. Every 2 years D. Every 5 years

ANS: B Rationale: Clients aged 65 and older should receive a tetanus toxoid every 10 years according to the CDC. Older adult clients do not need to receive tetanus toxoid yearly, every 2 years, or every 5 years.

1. An infant is being administered an immunization. Which statement provides an accurate description of an immunization? A. It is ideally administered to a pregnant woman prior to the infant's birth. B. It is the administration of an antigen for an antibody response. C. It produces many adverse reactions, particularly autism, in the infant. D. It protects the infant from exposure to infectious antibodies.

ANS: B Rationale: Immunization involves administration of an antigen to induce antibody formation. This protects the child against the actions of infectious agents; it does not prevent exposure to them. Immunization must be administered to the child following birth. There are limited adverse effects associated with immunization; autism is not among them.

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? A. Aspirin B. Acetaminophen C. Meperidine D. Heat application

ANS: B Rationale: 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 nursing student is scheduled to receive the hepatitis B series. What type of immunity will this immunization provide? A. Active immunity B. Passive immunity C. Innate immunity D. Natural immunity

ANS: B Rationale: The hepatitis B series produces passive immunity. Passive immunity occurs when antibodies are formed by the immune system of another person or animal and transferred to the host. Active immunity is produced by the person's own immune system in response to a disease caused by a specific antigen or administration of an antigen from a source outside the body, usually by injection. Innate or natural immunity, which is not produced by the immune system, includes the general protective mechanisms.

When teaching new parents about the benefits of adhering to the recommended vaccination schedule for their infant, the nurse should cite protection against which diseases? Select all that apply. A. Shingles B. Measles C. Varicella D. Poliomyelitis E. Hepatitis B

ANS: B, C, D, E Rationale: Measles, varicella, polio, and HBV are all within the schedule of infant vaccinations. The zoster vaccination to prevent herpes zoster (shingles) is recommended for adults 60 years and older.

2. 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? A. Renal insufficiency B. Hepatic failure C. Steroid therapy D. Age of 65 years

ANS: C Rationale: 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.

A client is scheduled to receive an immunization. In which client may the administration of a live vaccine be contraindicated? A. A client with renal impairment B. A client with hepatic failure C. A client taking steroid therapy D. A client over the age of 65

ANS: C Rationale: 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 client develops fever and arthralgia 4 days after the administration of tetanus toxoid. What reaction to the vaccine is this? A. Infectious process B. Anaphylaxis C. Serum sickness D. Distress syndrome

ANS: C Rationale: 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.

The nurse is preparing to administer a vaccine to a newborn. What action would the nurse take prior to administering the vaccine? A. Warm the vaccine to well above room temperature. B. Vigorously massage the chosen injection site. C. Check the infant's temperature. D. Divide the dose for administration to three injection sites.

ANS: C Rationale: The nurse should check the infant's temperature before administering any vaccine. Three injection sites are not normally required, and vigorous massage is not indicated. Warming the vaccine is not normally necessary.

A public health nurse is responsible for the administration of immunizations. After each immunization, the nurse should observe the client for evidence of anaphylaxis for how long? A. 1 minute B. 5 minutes C. 30 minutes D. 90 minutes

ANS: C Rationale: The nurse should observe for allergic reactions, which usually occur within 30 minutes. Time spans of 1 and 5 minutes may be too short for development of signs of anaphylaxis, and it is not necessary to observe for longer than 30 minutes.

When providing client teaching to parents regarding measles, mumps, and rubella vaccine administration, which is most important regarding the schedule for administration? A. It is administered at 1 to 2 months. B. It is administered at 3 to 4 months. C. It is administered at 5 to 6 months. D. It is administered at 12 to 15 months.

ANS: D Rationale: 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.

When instructing the parents of a child who has received immunization in the vastus lateralis, which reaction is most common in the days after the administration? A. Nausea, vomiting, and diarrhea B. Rash and edema C. Weakness and difficulty walking D. Tenderness and redness at the site

ANS: D Rationale: Pain, tenderness, and redness at the injection site are associated with the administration of immunizations. Nausea, vomiting, diarrhea, rash, edema, weakness, or difficulty walking are not generally reactions to immunizations.

A client has received a rubella immunization. The client was unaware that she was pregnant. What risk is associated with the administration of the rubella immunization in this client? A. Risk of development of the disease in the newborn B. Risk of low birth weight infant C. Risk of preterm labor D. Risk of birth defects

ANS: D Rationale: Rubella during the first trimester of pregnancy is associated with a high incidence of birth defects in the newborn. Rubella is not associated with the development of disease. Rubella is not associated with low birth weight or preterm labor.

An infant is seen in the clinic for first immunizations. When providing client teaching to the parent, which is no longer recommended for administration? A. Rubella and mumps vaccine B. Polio vaccine C. Diphtheria, pertussis, and tetanus vaccine D. Smallpox vaccine

ANS: D Rationale: Smallpox has been eradicated and is no longer administered to children. By 4 to 6 years of age, children should have received vaccinations for chickenpox, diphtheria, hepatitis A and B, influenza, measles, mumps, pertussis, polio, pneumococcal diseases, rubella, tetanus, and Haemophilus influenzae and rotavirus infections.

A nurse is administering a mumps vaccine to a child. Which medication should be available when administering an immunization? A. Diphenhydramine B. Hydroxyzine C. Physostigmine D. Epinephrine

ANS: D Rationale: 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.

It is important for the nurse to stay current with the recommendations for immunizations. Which source is most accurate regarding immunization guidelines? A. American Academy of Pediatrics B. National Shot Guide C. American Academy of Infectious Diseases D. Centers for Disease Control and Prevention

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

When providing a health promotion presentation to a group of seniors, how often should the nurse instruct the senior group to obtain influenza vaccines? A. One time only B. Every 10 years C. Two times per year D. Yearly

ANS: D Rationale: The influenza vaccine is administered yearly so that it can be formulated to react to the current strain of the flu. It is not administered as a single dose, every 10 years, or two times per year since strains vary year to year.