Chapter 31: Vaccines
Before administering the varicella vaccine, it is most important for the nurse to assess the patient for a history of allergy to: A) penicillin B) eggs C) neomycin D) milk
C) neomycin The varicella vaccine should not be given if a patient has an allergy to gelatin and/or neomycin.
Which of the following patients would be eligible to receive the influenza vaccine? A) the patient who is taking care of her son with HIV B) the patient who is pregnant C) the patient with an egg allergy D) the child who is 18 months old
D) the child who is 18 months old
The nurse would identify which of the following as examples of passive immunity? (Select all that apply) A) antibodies from an outside source, such as the mother's placenta and breast milk B) immune-globulin to provide antibodies against a specific disease C) antigen response to a pathogen D) immunizations E) exposure to a disease
A) antibodies from an outside source, such as the mother's placenta and breast milk B) immune-globulin to provide antibodies against a specific disease Passive immunity occurs when antibodies are given from another source. Antibodies gained from an outside source, such as the mother's placenta and breast milk is an example of natural passive immunity. Immunoglobulin antibodies injected into a person is an example of artificial passive immunity.
A 38-year-old migrant farm worker is seen in the clinic with a cut to his arm from an old metal drum. The patient has sutures placed, and a tetanus, diphtheria, and acellular pertussis vaccine is given. What is the nurse's most important action after the vaccine has been administered? A) the nurse provides the patient with a vaccine information statement about the tetanus, diphtheria, and acellular pertussis vaccine in the patient's primary language B) the nurse determines the exact date of the patient's last tetanus booster C) the nurse documents that the patient did not experience any side effects immediately following immunization D) the nurse provides the patient with a record of the immunization administered at the visit
A) the nurse provides the patient with a vaccine information statement about the tetanus, diphtheria, and acellular pertussis vaccine in the patient's primary language
The nurse is preparing to administer the tetanus vaccine to the patient. The nurse recognizes that the patient will be receiving: A) inactivated bacteria B) a toxoid C) inactivated viral antigen D) recombinant viral antigen
B) a toxoid The vaccine against tetanus is a toxoid.
Which statement about herpes zoster vaccine does the nurse identify as being true? Herpes zoster vaccine: A) is indicated for the treatment of patients at age 40 years B) is a live attenuated vaccine C) should be administered every other year D) prevented zoster in 90% of the people who received the vaccine
B) is a live attenuated vaccine The herpes zoster vaccine is indicated for the treatment of patients at age 50 years or older. It is a one time injection and it prevented zoster in 50% of the people who received the vaccine.
Which information will the nurse provide to a patient receiving tetanus toxoid? A) increase the fluid and fiber in your diet to prevent constipation B) soreness at the injection site is a common reaction C) lifetime immunity is achieved from this injection D) tetanus toxoid must be repeated weekly for 4 weeks
B) soreness at the injection site is a common reaction Myalgia at the injection site is a common side effect of tetanus toxoid. There is no need to repeat the toxoid weekly for 4 weeks, and the vaccine should not produce constipation. The toxoid usually is given approximately every 10 years.
An adult patient says, my children are being vaccinated. Are there any that I should have? What is the nurse's best reply? A) no, there are no vaccines that an adult needs B) yes, you need to remain current on several vaccines; check with your provider C) yes, you will need the same ones your children need D) no, you have probably had all of the childhood diseases by now
B) yes, you need to remain current on several vaccines; check with your provider While much emphasis is placed on regularly immunizing infants and children, adult immunizations are frequently overlooked. However, they are equally important to the health and well-being of this population.
The patient has been administered a live virus as a vaccine. The patient is most likely being vaccinated against which disease? A) tetanus B) diphtheria C) smallpox D) anthrax
C) smallpox A live virus is included in the smallpox vaccine. Toxoids are used to immunize against both tetanus and diphtheria. Anthrax requires a vaccine of inactivated bacteria.
Which is the first vaccine developed to prevent cancer? A) rotavirus B) pneumococcal disease C) meningococcal disease D) human papillomavirus
D) human papillomavirus Gardasil is the most widely used vaccine for the prevention of cervical, vulvar, vaginal, and anal cancers caused by human papillomavirus (HPV).
The community health nurse is assessing a child who has a rash. The child is found to have measles. What is the nurse's best action? A) take no action; let the disease process run its course B) take the child to the nearest emergency department for treatment C) tell the parent to stay away from the child to avoid infection D) report the measles to public health officials
D) report the measles to public health officials Health care providers are responsible for reporting cases of vaccine-preventable diseases to public health officials, who then make weekly reports to the Centers for Disease Control and Prevention. These data identify whether an outbreak is occurring and the impact of immunization policies and procedures.
The patient has been administered a toxoid. The patient is most likely being vaccinated against which disease? A) diphtheria B) human papillomavirus (HPV) C) hepatitis B D) mumps
A) diphtheria Vaccination against diphtheria is performed with administration of a toxoid. Human papillomavirus and hepatitis B both require a recombinant viral antigen vaccine; mumps requires a live attenuated virus.
Once a child has received a vaccination, what action is the nurse's priority? A) monitor for possible anaphylaxis B) assess for muscle pain C) treat pain at the injection site D) assess for infection
A) monitor for possible anaphylaxis Anaphylaxis is a potentially life-threatening adverse reaction to vaccines. Muscle pain and pain at the injection site can occur, but assessment and treatment of these is not the primary action. Infection is not likely from a vaccination.
Newborns receive immunities via the transfer of maternal antibodies across the placenta. This is known as: A) natural, passive immunity B) acquired, passive immunity C) natural, active immunity D) acquired, active immunity
A) natural, passive immunity
With the help of an interpreter, the nurse has just immunized a 35-year-old woman with the tetanus, diphtheria, and acellular pertussis vaccine and the vaccine against measles, mumps, and rubella. It is essential that the nurse proceed with which action(s)? (Select all that apply) A) provide a vaccine information statement in the patient's preferred language for each vaccine received B) document in the patient's record the date; site and route of administration; vaccine type, manufacturer, lot number, and expiration date; and the name, business address, and title of the person administering the vaccine C) administer a dose of ibuprofen to prevent postimmunization fever D) instruct the patient to call about any injection site soreness
A) provide a vaccine information statement in the patient's preferred language for each vaccine received B) document in the patient's record the date; site and route of administration; vaccine type, manufacturer, lot number, and expiration date; and the name, business address, and title of the person administering the vaccine
The nurse is preparing to administer routine, recommended immunizations to an immunocompromised 1-year-old child. What is the most important information to know prior to administering a vaccination? A) the type of vaccine to be administered to the child B) the child presents with a temperature of 99.8 F C) the child's vaccine report shows immunizations were received on time D) the child did not experience adverse reactions to prior immunizations
A) the type of vaccine to be administered to the child Some vaccines contain live viruses which may have the potential to cause disease symptoms when given to a patient who is immunocompromised.
The nurse is preparing to administer vaccines to a young child. What will the nurse do initially? A) rub the site of the vaccination with alcohol B) explain active and passive immunity to the child and caregivers C) ask the caregivers about food allergies and over-the-counter medications D) tell the child to lie on the stomach to receive the vaccines
C) ask the caregivers about food allergies and over-the-counter medications Before immunizations are administered, children and their caregivers should be questioned regarding their use of prescription and over-the-counter medications, including herbal preparations and any food or drug allergies. Depending on the patient's allergies, the other interventions listed may not occur if it is determined that it is too dangerous for the patient to receive the vaccine.
The nurse is preparing to administer the hepatitis A vaccine to the patient. The nurse recognizes that the patient will be receiving: A) inactivated bacteria B) a toxoid C) inactivated viral antigen D) recombinant viral antigen
C) inactivated viral antigen The vaccine against hepatitis A is an inactivated viral antigen.
The patient is scheduled to receive a measles vaccine. The nurse recognizes that the patient will be receiving: A) inactivated viral components B) inactivated virus C) live virus D) live attenuated virus
C) live virus The measles vaccine is a live virus.
The father of a 4-month-old infant calls in to the clinic reporting that his child is having a reaction to immunizations. What is the most important piece of information the nurse should elicit? A) the time the immunization was received B) whether the father has given the infant any acetaminophen C) the signs and symptoms the infant is experiencing D) the sites used to administer the immunizations
C) the signs and symptoms the infant is experiencing
An 18-month-old child is accompanied to the clinic by her grandmother, the child's legal guardian. The grandmother reports that the child is due for her fourth diphtheria, tetanus, and acellular pertussis vaccination. The nurse determines that the child should not receive the diphtheria, tetanus, and acellular pertussis vaccine that day for which reason? A) the child received a varicella vaccine 2 weeks ago B) the grandmother is receiving chemotherapy C) the third diphtheria, tetanus, and acellular pertussis dose was administered 4 months ago D) the nurse sees that the child has a runny nose during the visit
C) the third diphtheria, tetanus, and acellular pertussis dose was administered 4 months ago The fourth dose of the diphtheria, tetanus, and acellular pertussis vaccine (commonly known as DTaP or Tdap) is not due until the child is between 4 to 6 years of age.
A 14-year-old girl requests a vaccination for human papillomavirus (HPV). After the nurse administers the first dose, which of the following is important to include in the patient's teaching? A) HPV prevents all sexually transmitted diseases B) pap smears are no longer needed after the HPV vaccination C) the patient need to notify the health care provider about pain at the injection site D) the date the patient needs to return to the clinic for the next HPV dose
D) the date the patient needs to return to the clinic for the next HPV dose Typically, a patient receives 3 separate doses of the HPV vaccine. Pain at the injection site is common for many vaccines so the nurse can offer suggestions for the relief of pain such as cold compresses and acetaminophen for soreness or fever. HPV does not prevent all sexually transmitted diseases and pap smears are still needed after the HPV vaccination.
The nurse is preparing to administer varicella vaccine to a young woman. Which of the following findings has the greatest implication for this young woman's care? A) the patient tells the nurse she is "deathly afraid of needles" B) the medical record indicates that the patient is allergic to eggs C) the medical history indicates that the patient had leukemia as a child D) the patient appears to be pregnant
D) the patient appears to be pregnant Varicella is a live vaccine and is contraindicated in pregnancy.