PrepU Chapter 18
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?
"Vaccinations are not without some risks, but these are far exceeded by the potential benefits." 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.
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?" 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.
A client has been exposed to hepatitis A after eating at a restaurant. The client's care provider has prescribed a dose of hepatitis A immune globulin. the nurse learns that the client has a history of chronic renal failure and successfully received a donor kidney three years ago. What is the nurse's best action?
Administer the immune globulin as prescribed Organ transplants do not contraindicate the use of immune globulins, which do not differ significantly from the antibodies that are produced by active immunity. There would be no obvious reason to admit the client for care or to increase the client's fluid intake.
Which is an example of artificially acquired active immunity? (Select all that apply.)
Administration of the varicella vaccine to an individual who has no immunity to the disease. Administration of the influenza vaccine to an individual who has no immunity to the disease. Administration of the rubella vaccine to an individual who has no immunity to the disease.
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 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; male homosexuals; IV drug users; household contacts of HBV carriers; and residents and staff of institutions for mentally challenged people.
When educating a group of nursing students on immunologic agents, the nurse explains about a particular kind of immunity that develops by injecting ready-made antibodies found in the serum of immune individuals or animals. The nurse is referring to what kind of immunity?
Passive immunity The nurse is referring to passive immunity. The injection of ready-made antibodies found in the serum of immune individuals or animals is called passive immunity. When a person is exposed to antigens, the body begins to form antibodies. This is called active immunity. Humoral and cell-mediated immunity involve the action by B lymphocytes and T lymphocytes.
Which statement should the nurse include in a discussion about passive immunity?
Passive immunity provides temporary protection from disease. Passive immunity results from parenteral administration of immune serum containing disease-specific antibodies to a nonimmune person. Passive immunity is only temporary, and the person still needs a vaccine against a specific disease to develop antibodies that provide long-term immunity. It is inaccurate to characterize passive immunity as being safer than active immunity. Administration of antigens results in active immunity.
A nurse is preparing a presentation to a local community group about biological weapons. The nurse would identify which disease as lacking an available vaccine?
Plague There is no vaccine available for plague. There is a vaccine for anthrax, but it is available only for military use. There is a vaccine for smallpox and a botulinum toxoid for botulism.
The school nurse is participating in a program to immunize students against human papillomavirus (HPV). What benefit should the nurse describe to students and their families?
Reduced risk for cervical cancer The HPV vaccine directly reduces the risk of cervical cancer, but not the risk of other sexually transmitted infections, PID, or polycystic ovary syndrome.
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 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 male client is being assessed after consuming packaged salad that is known to have been contaminated with hepatitis A. The use of hepatitis A immune globulin is being considered by the care team. What assessment finding should the nurse prioritize for communicating to the client's provider?
The client received hepatitis A immune globulin under similar circumstances one year ago The chances of a hypersensitivity reaction increase with repeat administrations of immune globulins. The nurse should ensure the provider is aware of the fact that the client received this immune globulin last year. The client's alcohol use is on the threshold of being problematic but would not be the priority. Flu-like symptoms after the influenza vaccine do not preclude the use of hepatitis immune globulin. Similarly, allergies to NSAIDs or penicillins do not rule out the safe use of this immune globulin.
Which statement best describes the recommended vaccination schedule for a 63-year-old client?
a tetanus-diphtheria booster every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age
A female health care worker has received her 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 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 landscaper has sought care because of a puncture wound to her foot and the provider has prescribed 250 units of the tetanus immune globulin. In preparation for administration, the nurse should:
assess the skin integrity of potential intramuscular injection sites. The tetanus immune globulin is administered by the IM route. Education is likely necessary but the administration of the immune globulin is the priority. Tetany develops several days after tetanus infection.
The nurse educator is teaching a class of community leaders about immunologic agents. To minimize the concern regarding adverse effects of vaccinations, the nurse should include which mild reactions in the teaching plan?
chills and fever Chills and fever are mild adverse reactions observed after administration of vaccines. None of the other options are generally associated with mild adverse reactions to vaccines.
A client is scheduled to receive an immunization. In which client may the administration of a live vaccine be contraindicated?
client taking steroid therapy 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.
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.
measles varicella poliomyelitis hepatitis B 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.
Based on your work as a nurse in a geriatric clinic, the nurse knows that older adults should receive a pneumococcal vaccine:
once at 65 years of age. Recommended immunizations for older adults include one-time administration of the pneumococcal vaccine at 65 years of age. A second dose may be given at 65 if a first dose was administered 5 years previously.
The administration of immune globulins or antivenins to a client is a form of what type of immunity?
passive immunity Passive immunity occurs when immune globulins or antivenins are administered. This type of immunity provides the individual with ready-made antibodies from another human or an animal. When a person is exposed to certain infectious microorganisms (the source of antigens), the body actively builds an immunity (forms antibodies) to the invading microorganism. This is called active immunity. Artificially acquired active immunity occurs when an individual is given a killed or weakened antigen, which stimulates the formation of antibodies against the antigen. The antigen does not cause the disease, but the individual still manufactures specific antibodies against the disease. Naturally acquired active immunity occurs when the person is exposed to and experiences a disease and the body manufactures antibodies to provide future immunity to the disease.
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?" The nurse should take an approach that is respectful and which fosters further dialogue without dismissing or downplaying the parents' concerns.
Which response best demonstrates a nurse's understanding of the risk immunizations pose concerning the development of resulting illness?
"Immunizing agents are quite safe, and risks of the diseases they prevent are greater than the risks of the vaccines." In general, immunizing agents are quite safe, and risks of the diseases they prevent are greater than the risks of the vaccines. However, risks and benefits for particular recipients should be considered because no vaccine is completely effective or completely safe. Some people may develop a disease after being immunized against it. However, if this happens, symptoms are usually less severe and complications are fewer than if the person had not been immunized. Adverse effects are usually mild and of short duration. Although the FDA evaluates vaccine safety before and after a vaccine is marketed, some adverse effects become apparent only after a vaccine is used in a large population.
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?" 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 client prescribed prednisone 40 mg daily should be provided what information about immunizations by the nurse?
"You should wait at least 3 months after chemotherapy to obtain a live vaccine immunization." 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 being given a live virus vaccine. Immunizations are not contraindicated with short-term use (less than 2 weeks) or low to moderate doses (less than 20 mg daily) of prednisone. None of the other options present accurate information concerning immunizations for a client currently prescribed prednisone.
For the first time, a 10 year-old female has received an IM injection of Gardasil. What follow-up education should the nurse provide?
"You'll have to get another shot in around 2 months." Gardasil requires a series, a with a second dose two months after the first. A fever is not expected, nor is stomach pain. Without the appropriate boosters, the client will not be protected later in life.
An adult client is scheduled to receive the inactivated hepatitis A vaccine. The nurse should provide what education to the client?
"You'll need another dose of the vaccine in six to 12 months from now." Hepatitis A vaccine requires a repeat dose in six to twelve months. There is no prohibition against drinking alcohol after receiving the vaccine. B cells take more than 48 hours to create the necessary immunoglobulins for conferring immunity. The hepatitis A vaccine does not require an annual booster.
A neonate who weighs 7 lbs, 8 oz kg is prescribed the hepatitis B immune globulin at a dose of 0.06 mL/kg IM. To one decimal place, what dose should the nurse administer?
0.2 The neonate's weight in kg is 3.41 kg (7.5 lbs divided by 2.2). The prescribed dose is 0.06 X 3.41, which yields 0.2 mL to one decimal place.
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 IM The nurse will administer 0.5 mL. This is the recommended dose for adults and children older than 15 months of age.
The nurse should be prepared to administer an infant's first dose of polio vaccine at what age?
2 months The first recommended dose of polio vaccine is at age 2 months
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 Clients who have been on a systemic corticosteroid longer than 2 weeks should wait 3 months before receiving a live virus vaccine.
The nurse is working in a clinic which is providing the annual influenza A vaccine for staff and residents of a large long-term care facility. Which client poses the greatest concern associated with being vaccinated?
A resident who received four units of packed red blood cells for a gastrointestinal bleed three weeks ago Recent blood transfusions contraindicate the use of vaccines because there is an associated risk of an unpredictable immune response. The influenza vaccine, like most vaccines, is not contraindicated during breastfeeding. Old age, COPD and recent hepatitis vaccinations are not contraindications.
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 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 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.
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). 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.
Which is an example of artificially acquired active immunity? (Select all that apply.)
Administration of the varicella vaccine to an individual who has no immunity to the disease. Administration of the influenza vaccine to an individual who has no immunity to the disease. Administration of the rubella vaccine to an individual who has no immunity to the disease. Administration of the varicella, influenza, and rubella vaccine to an individual who has no immunity to the disease are examples of artificially acquired active immunity.
A toddler has received the varicella vaccine at age 12 months, as scheduled. The nurse should teach the toddler's parents that a booster will be necessary at what age?
Age 4 to 6 years A booster of varicella is recommended at age 4 to 6 years.
Which is an example of naturally acquired active immunity? (Select all that apply.)
An individual who is exposed to pertussis for the first time and has no immunity to the disease. An individual who is exposed to chickenpox for the first time and has no immunity to the disease.
The administration of immunizations to a client is a form of what type of immunity?
Artificial active immunity Immunizations are a form of artificial active immunity.
An adult client being treated for breast cancer inquired about required vaccinations. What information should the nurse provide to this client?
Avoid all live vaccines. Clients with active malignant disease should not receive live vaccines. A tetanus-diphtheria-pertussis booster is not likely necessary, and there is no indication for a pneumococcal immunization. When possible, clients should have needed immunizations 2 weeks before or 3 months after immunosuppressive radiation or chemotherapy treatments.
When describing the action of vaccines, the nurse identifies their action as primarily affecting:
B lymphocytes. Vaccines exert their action on B cells, which in turn stimulate the formation of antibodies. Interleukins, histamine release, and effector T cells are not affected by vaccines.
A patient with a history of chronic cough is suspected of having pulmonary tuberculosis. Which vaccination is used to prevent the condition?
BCG vaccine For the prevention of pulmonary tuberculosis (TB) in high-risk populations such as health care workers, infants, and children in endemic areas, a BCG vaccination is given. The MMR vaccine is used for preventing measles, mumps, and rubella. The DPT vaccine is used for the prevention of diphtheria, pertussis, and tetanus. IPV is an inactivated polio virus used to prevent polio.
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 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 Antivenins are used for passive, transient protection from the toxic effects of bites by black widows, rattlesnakes, copperheads, cottonmouth, and coral snakes.
What is the best source of information for current recommendations regarding immunizations and immunization schedules?
Centers for Disease Control and Prevention 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 (http://www.cdc.gov).
A nurse should warn a client about which adverse reactions that can occur after the administration of influenza vaccine (Fluzone)? (Select all that apply.)
Chills Fever Lethargy Muscle aches 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 For cutaneous anthrax, ciprofloxacin or doxycycline would be used. Ribavirin would be used for hemorrhagic fever; streptomycin or gentamicin would be used for tularemia.
Which vaccine is recommended for adolescents and adults?
Diphtheria Immunization against diphtheria and tetanus is recommended in adolescents and adults; following initial immunization, patients should receive booster shots every ten years. The rotavirus vaccine is one of the routine immunizations recommended for children. Immunization against typhoid is not routine.
The elderly client returns from a health care visit and asks the nurse why another flu shot was necessary this year because the client got one last year. The nurse's best response is:
Each year a new vaccine is developed based on the strains most prevalent. Immune serums are the biologic products used for passive immunity. They act rapidly to provide temporary (for 1-3 months) immunity in people exposed to or experiencing a particular disease. The goal of therapy is to prevent or modify the disease process; to do this, the most prevalent strains must be identified on an annual basis.
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 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 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 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 occurs more commonly with the use of vaccines than with immune sera.
False Serum sickness occurs more often when immune sera are used.
Serum sickness results from the overuse of vaccines.
False Serum sickness occurs when a host with circulating injected antibodies responds by producing its own antibodies to those injected.
The nurse is teaching a course to students about immunologic agents. In order for the students to understand active immunity, the nurse explains that there are agents that provide active immunity. Which is an active immunity agent?
Haemophilus influenzae type B conjugate A vaccine is an active immunity agent. Haemophilus influenzae type B conjugate is a live vaccination. The remainaing answer options offer agents that are either Immune globulins or antivenins which are passive immunity agents.
The perinatal nurse recognizes that what vaccine can be safely given to a neonate?
Hepatitis B 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 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 client is to receive a typhoid vaccine. The nurse would prepare to administer this vaccine in which site?
Into the fatty tissue of the upper arm The typhoid vaccine is administered subcutaneously, often into the fatty tissue of the upper arm.
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. 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.
The nurse is teaching the parents of a child who has received immunizations and possible adverse effects. What would the nurse identify as common adverse effects? (Select all that apply.)
Nodule at the injection site Fretfulness Chills Anorexia Common adverse effects include moderate fever, rash, malaise, chills, fretfulness, drowsiness, anorexia, vomiting, irritability, and pain, redness, swelling, and nodule formation at the injection site.
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 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 patient develops fever and arthralgia 4 days after the administration of tetanus toxoid. What reaction to the vaccine is this?
Serum sickness 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, serum sickness, 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 Vaccine to prevent shingles is available for adults aged 60 years and older.
What would the nurse identify as a vaccine that is a toxoid?
Tetanus 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 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 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.
A 65-year-old client has come to the clinic after receiving the shingles vaccine two weeks ago. The client asks the nurse how long the immunity will last. The nurse would include which information in the explanation?
The varicella virus (shingles) vaccine protects the recipient for several years or for life. The varicella virus (shingles) vaccine protects the recipient for several years or, in some cases, for life. There is no recommended booster vaccine available.
The college health nurse is providing health education for freshmen. Which piece of information about immunizations is applicable to individuals of this age group?
The yearly administration of flu vaccine is recommended. 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.
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 Immunization for tuberculosis occurs worldwide, but it is not routinely used in the United States.
To prevent meningococcal infections, the nurse would administer:
Vaccine Meningococcal infections would be prevented by a vaccine. A toxoid is a type of vaccine made from the toxins produced by the organism. Immune globulins and antivenin are examples of immune sera.
When describing the use of vaccines to a local community group, what would the nurse include?
Vaccines are used to provide active immunity. Vaccines provide active immunity. They promote the formation of antibodies against a specific disease. The person experiences an immune response without having to suffer the full course of the disease. Severe reactions are rare.
A nurse should screen clients of child-bearing age for pregnancy as the administration of which vaccines is contraindicated during pregnancy? (Select all that apply.)
Varicella Measles Mumps Rubella The measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy, especially during the first trimester, because of the danger for birth defects. **Influenza is NOT contraindicated
What would contraindicate the administration of scheduled immunizations at a client visit for a 6-month-old infant?
a low-grade fever 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 client receives an immunization. The nurse interprets this as providing the client with which type of immunity?
artificially acquired active immunity Artificially acquired active immunity occurs when an individual is given a killed or weakened antigen, which stimulates the formation of antibodies against the antigen. The antigen does not cause the disease, but the individual still manufactures specific antibodies against the disease. Naturally acquired active immunity occurs when the person is exposed to and experiences a disease and the body manufactures antibodies to provide future immunity to the disease. Passive immunity occurs when immune globulins or antivenins are administered. This type of immunity provides the individual with ready-made antibodies from another human or an animal. When a person is exposed to certain infectious microorganisms (the source of antigens), the body actively builds an immunity (forms antibodies) to the invading microorganism. This is called active immunity.
The nurse is preparing to administer a vaccine to a newborn. Before administering the vaccine, the nurse should:
check the infant's temperature. 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 1-year-old child will receive her 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?
cough and fever 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 nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization?
epinephrine
A nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization?
epinephrine 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 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?
every 10 years
A client about to receive an injection of influenza vaccination should be informed of the possibility of experiencing which short-term adverse effect? Select all that apply.
malaise muscle aches low-grade fever erythema at the injection site Influenza vaccine via injection may cause pain, induration, and erythema at injection sites and flu-like symptoms such as chills, fever, malaise, and muscle aches. Anorexia is not generally associated with the short-term adverse effects of an influenza vaccination.
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?
risk of birth defects 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.
A client is scheduled to receive an immunization. Administration of live vaccine is contraindicated in the client with:
steroid therapy
Middle-aged adults and health care workers should receive which collection of immunizations?
tetanus-diphtheria-pertussis, hepatitis B vaccine once, and influenza vaccine annually
When educating a group of nursing students on immunologic agents, the nurse refers to a substance that is attenuated (or weakened) but still capable of stimulating the formation of antitoxins. The nurse is referring to:
toxoids The nurse is referring to toxoids. A toxoid is a toxin which is weakened but still capable of stimulating the formation of antitoxins. Toxoids are administered to stimulate the immune response within the body to specific antigens or toxins. These agents must be administered before exposure to the disease-causing organism. Vaccines are attenuated or killed antigens which are capable of stimulating antibody production and creating immunity. Immune globulins are antibody-containing solutions formed to specific antigens and are obtained from human or animal blood. Vaccines, immune globulins, and antivenins do not stimulate antitoxin formation.
A nurse prepares to administer antithymocyte immune globulin. The nurse understands that this is used to:
treat acute renal transplant rejection. 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.
A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster?
zoster vaccine 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.
