49 Immunologic Agents
A client who is right-handed is to receive a booster injection for a previous vaccination. The nurse prepares to administer the injection at which site? A) Right arm B) Left arm C) Right leg D) Left leg
Ans: A Feedback: The nurse should use the dominant arm, in this case, the right arm, for the injection to help aid in the absorption.
A nurse is caring for a client who has been bitten by a coral snake. Which of the following would the nurse expect to administer to this client? A) Antivenin B) Toxoid C) Vaccine D) Immune globulins
Ans: A Feedback: Antivenin of micrurus fulvius is used in passive transient protection from the toxic effects of the venom of the coral snake found in the United States. The most effective response is obtained when the drug is administered within 4 hours of exposure. Vaccines, toxoids, and immune globulins are examples of immunologic agents and are not used in treating a snake bite.
A nurse is educating a group of nursing students about the immediate reactions that may occur after administering antivenins. Within which of the following time periods will the immediate reaction be seen if the client is sensitive to the antivenin? A) 30 minutes B) 60 minutes C) 90 minutes D) 120 minutes
Ans: A Feedback: The immediate reactions usually occur within 30 minutes of administration of the antivenin. The antivenins may cause various reactions, with hypersensitivity being the most severe. Symptoms include apprehension; flushing; itching; urticaria; edema of the face, tongue, and throat; cough; dyspnea; vomiting; cyanosis; and collapse.
When describing humoral immunity to a group of nursing students, which of the following would the instructor most likely include? Select all that apply. A) B lymphocytes are involved. B) An antigen-antibody response occurs. C) An immunity that is independent of cell-mediated immunity occurs. D) T lymphocytes are activated. E) The immunity protects the body against bacterial, viral, and fungal infections.
Ans: A, B Feedback: Humoral immunity involves the action of B lymphocytes and protects the body against bacterial and viral infections. Humoral immunity is based on the antigen-antibody response. Humoral immunity is interdependent with cell-mediated immunity. Cell-mediated immunity involves the action of T lymphocytes and protects against bacterial, viral, and fungal infection.
Human immune globulin intravenous (IGIV) products have been associated with renal problems. The nurse understands that which clients should not receive IGIV? Select all that apply. A) Clients with diabetes mellitus B) Clients 65 years of age or older C) Clients receiving vancomycin D) Clients with pre-existing renal disease E) Clients receiving cephalexin
Ans: A, B, C, D Feedback: Human immune globulin intravenous (IGIV) products have been associated with renal problems; therefore, a nurse should not administer IGIV to clients with a predisposition to acute renal failure (those with pre-existing renal disease), those with diabetes mellitus, those 65 years of age and older, or those receiving nephrotoxic drugs (vancomycin).
A nurse should include which of the following information when educating the client's parents on the varicella vaccine? Select all that apply. A) Explain the risk of contracting vaccine-preventable diseases. B) Explain the benefits of immunization. C) Provide the date for return for the next vaccination. D) Discuss common adverse reactions. E) Instruct the parents to bring immunization records to all visits.
Ans: A, B, C, D, E Feedback: The following information should be included when educating the parents of a client receiving a vaccination: explain the risk of contracting vaccine-preventable diseases, explain the benefits of immunization, instruct the parents to bring immunization records to all visits, provide the date for return for the next vaccination, discuss common adverse reactions, and instruct parents to report any unusual or severe adverse reactions after the administration of a vaccination.
A nurse identifies a nursing diagnosis of Acute Pain for a client receiving a vaccine. Which of the following would the nurse include in the client's plan of care to address this problem? Select all that apply. A) Administering acetaminophen every 4 hours B) Providing for adequate rest periods C) Ensuring that the environment is stimulating D) Applying compresses to the injection site E) Limiting the client's access to fluids
Ans: A, B, D Feedback: For the client with acute pain related to the administration of a vaccine, the nurse would administer prescribed acetaminophen; provide for frequent rest periods in a quiet, nonstimulating environment; apply warm or cool compresses to the injection site; and encourage fluid intake.
A nurse should warn a client about which of the following adverse reactions that can occur after the administration of influenza vaccine (Fluzone)? Select all that apply. A) Chills B) Fever C) Hypotension D) Lethargy E) Muscle aches
Ans: A, B, D, E Feedback: Adverse reactions from the administration of vaccines or toxoids are usually mild and include chills, fever, muscle aches and pains, rash, and lethargy. Hypotension is not associated with vaccine administration.
When teaching a client who is receiving cytomegalovirus immune globulin, the nurse would alert the client to the possibility of which of the following ? Select all that apply. A) Urticaria B) Angioedema C) Constipation D) Headache E) Chills
Ans: A, B, D, E Feedback: The most common adverse reactions to the administration of cytomegalovirus immune globulin (CytoGam) include urticaria, angioedema, erythema, malaise, nausea, diarrhea, headache, chills, and fever. Constipation is not a common adverse reaction.
A nurse is preparing to administer an immunologic drug that produces active immunity. Which of the following might the nurse be administering? Select all that apply. A) Vaccines B) Antibodies C) Toxoids D) Antigens E) Immune globulin
Ans: A, C Feedback: Both vaccines and toxoids are administered to stimulate the body's immune response to specific antigens or toxins. These agents must be administered before exposure to the disease-causing organism. The initiation of the immune response, in turn, produces resistance to a specific infectious disease. The immunity produced in this manner is active immunity.
A nurse is reviewing a client's medical record and determines that the client has naturally acquired active immunity. Which of the following would most likely apply? Select all that apply. A) The client who is exposed to chickenpox for the first time and has no immunity to the disease B) Administration of the varicella vaccine to an individual who has no immunity to the disease C) An individual who is exposed to pertussis for the first time and has no immunity to the disease D) Administration of the influenza vaccine to an individual who has no immunity to the disease E) Administration of the rubella vaccine to an individual who has no immunity to the disease
Ans: A, C Feedback: 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. This would be an individual who is exposed to chickenpox or pertussis for the first time and has no immunity to the disease. 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. Administration of a vaccine to an individual who has no immunity would be an example of artificially acquired active immunity.
1. A nursing instructor is describing the concept of immunity. The instructor determines that the teaching was successful when the students identify that cell-mediated immunity protects the body against what type of infections? Select all that apply. A) Viral B) Protozoal C) Fungal D) Bacterial E) Helminth
Ans: A, C, D Feedback: Cell-mediated immunity protects the body against viral, bacterial, and fungal infections.
A nurse is teaching a client about the use of immune globulin. Which of the following would the nurse include? Select all that apply. A) Globulins are proteins present in blood serum or plasma that contain antibodies. B) Globulins are given to provide active immunity against disease. C) Immune globulin can be obtained from human and animal blood. D) Clients receiving immune globulins receive antibodies only to the diseases to which donor blood is immune. E) The onset of protection is rapid but the duration of action is long (6 to 12 months).
Ans: A, C, D Feedback: The following is true in regard to the use of immune globulin: globulins are proteins present in blood serum or plasma that contain antibodies, globulins are given as passive immunity against disease, immune globulin can be obtained from human and animal blood, clients receiving immune globulins receive antibodies only to the diseases to which donor blood is immune, and the onset of protection is rapid but the duration of action is short (1 to 3 months).
Vaccines containing live organisms are not administered to clients taking which of the following drugs as insufficient numbers of antibodies are produced to prevent the disease because these drugs suppress the immune system? Select all that apply. A) Methylprednisolone (Medrol) B) Ciprofloxacin (Cipro) C) Prednisolone (Orapred) D) Paclitaxel (Taxol) E) Vincristine (Oncovin)
Ans: A, C, D, E Feedback: Vaccines containing live organisms are not administered to clients taking corticosteroids (methylprednisolone and prednisolone) or antineoplastic drugs (paclitaxel and vincristine) and those receiving radiation therapy as insufficient numbers of antibodies are produced to prevent the disease because these drugs suppress the immune system.
When administering antivenin to a client, the nurse is aware that this drug is used for passive, transient protection from which of the following bites? Select all that apply. A) Black widow spider B) Canine C) Human D) Rattlesnake E) Copperhead snake
Ans: A, D, E Feedback: Antivenins are used for passive, transient protection from the toxic effects of bites by black widow spiders and rattlesnakes, copperhead snakes, cottonmouth snakes, and coral snakes.
Which of the following would the nurse most likely identify as a nursing diagnosis for a client who is receiving an immunization? A) Risk for Infection B) Acute Pain C) Hyperthermia D) Ineffective Coping
Ans: B Feedback: The client who is receiving an immunization would most likely experience pain at the injection site; therefore, Acute Pain would be most appropriate. If the drug was not given, then the client would be at risk for infection. Although fever may occur, Hyperthermia as a nursing diagnosis would be inappropriate. Ineffective Coping would not be associated with immunologic agents.
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 determines that the teaching was successful when the students identify this substance as which of the following? A) Antivenins B) Toxoids C) Vaccines D) Immune globulins
Ans: B Feedback: The nurse is referring to toxoids. A toxoid is a toxin that 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 that 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.
After administering the pneumococcal vaccine (Pneumovax) to a client, the nurse documents which of the following in the client's chart? Select all that apply. A) Date of next vaccination B) Vaccine lot number C) Vaccine expiration date D) Route and site of vaccine administration E) Name, address, and title of client vaccinated
Ans: B, C, D Feedback: After administering a vaccine to a client, the nurse documents the following information in the client's chart: date of vaccination, route and site, vaccine type, manufacturer, lot number, expiration date, and name, address, and title of individual administering the vaccine.
Several clients have come to the clinic for immunizations. When reviewing their medical records, the nurse identifies which of the following as a contraindication for the administration of vaccines and toxoids? Select all that apply. A) Acute nonfebrile illness B) Leukemia C) Chronic prednisone therapy D) HIV E) Clients older than 70 years of age
Ans: B, C, D Feedback: Vaccines and toxoids are contraindicated with acute febrile illnesses, leukemia, lymphoma, immunosuppressive illness (HIV) or drug therapy (prednisone), and nonlocalized carcinoma.
A nurse should screen clients of childbearing age for pregnancy as the administration of which of the following vaccines is contraindicated during pregnancy? Select all that apply. A) Influenza B) Varicella C) Measles D) Mumps E) Rubella
Ans: B, C, D, E Feedback: The measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy, especially during the first trimester, because of the danger for birth defects.
A client is traveling to a foreign country. A nurse should recommend vaccination against which of the following before travel to endemic areas? Select all that apply. A) Varicella B) Diphtheria C) Lyme disease D) Tetanus E) Cholera
Ans: B, C, E Feedback: A nurse should recommend vaccination against the following before travel to endemic areas: cholera, diphtheria, Japanese encephalitis, Lyme disease, smallpox, typhoid, and yellow fever. Immunization against varicella and tetanus are diseases prevented by routine vaccination.
After teaching a class to a group of nursing students about immunity, the instructor determines that the teaching was successful when the students identify which of the following as an example of passive immunity? Select all that apply. A) An individual who is exposed to chickenpox for the first time and has no immunity to the disease B) Administration of botulism immune globulin (BabyBIG) for the treatment of infant botulism C) An individual who is exposed to pertussis for the first time and has no immunity to the disease D) Administration of Crotalidae polyvalent immune Fab (CroFab) for the treatment of mild to moderate North American rattlesnake bites E) Administration of the rubella vaccine to an individual who has no immunity to the disease
Ans: B, D Feedback: 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. Administration of botulism immune globulin (BabyBIG) for the treatment of infant botulism or administration of Crotalidae polyvalent immune Fab (CroFab) for the treatment of mild to moderate North American rattlesnake bites are examples of passive immunity.
Which of the following is an example of artificially acquired active immunity? Select all that apply. A) An individual who is exposed to chickenpox for the first time and has no immunity to the disease B) Administration of the varicella vaccine to an individual who has no immunity to the disease C) An individual who is exposed to pertussis for the first time and has no immunity to the disease D) Administration of the influenza vaccine to an individual who has no immunity to the disease E) Administration of the rubella vaccine to an individual who has no immunity to the disease
Ans: B, D, E Feedback: 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. Administration of the varicella vaccine, administration of the influenza vaccine, and administration of the rubella vaccine to an individual who has no immunity to the disease are examples of artificially acquired active immunity. 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.
A client comes to the clinic and tells the nurse that close family members are suspected of having pulmonary tuberculosis. Which of the following would the nurse recommend as a preventative measure? A) MMR vaccine B) DPT vaccine C) BCG vaccine D) IPV vaccine
Ans: C Feedback: 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 preventing diphtheria, pertussis, and tetanus. IPV is an inactivated polio virus used to prevent polio.
After teaching a group of nursing students about the various immunologic drugs, the instructor determines that the teaching was successful when the students identify which of the following as a viral vaccine? Select all that apply. A) Haemophilus influenza type B conjugate B) Typhoid C) Mumps D) Avian influenza E) Rabies
Ans: C, D, E Feedback: Mumps, avian influenza, and rabies are virus vaccines. Haemophilus influenza type B conjugate and typhoid are bacterial vaccines.
A nurse obtains a thorough allergy history prior to administering vaccines to a client. An allergy to which of the following would alert the nurse to a contraindication for administering the measles, mumps, rubella, and varicella vaccines? Select all that apply. A) Eggs B) Pollen C) Gelatin D) Amoxicillin E) Neomycin
Ans: C, E Feedback: The measles, mumps, rubella, and varicella vaccines are contraindicated in clients allergic to gelatin, neomycin, or a previous dose of one of the vaccines.
A forest ranger arrives at a community clinic for prophylactic vaccination. Which of the following vaccines would be most important to be administered to the ranger? A) MMR vaccine B) Varicella vaccine C) Rotavirus vaccine D) Rabies vaccine
Ans: D Feedback: Due to the high numbers of animals in the forest, the ranger should receive the rabies vaccine as prophylaxis as he is at high risk for contracting the virus. The MMR vaccine is used in preventing measles, mumps, and rubella. The varicella vaccine is used in preventing chickenpox, and the rotavirus vaccine is used in preventing gastroenteritis caused by the rota virus.
A child is brought by his parents to the health care center for MMR vaccination. On taking the medical history, the nurse understands that the child had received an antivenin injection for a snake bite 2 days before. Which of the following is the most appropriate time period for administration of live vaccines to the child? A) After 1 to 2 weeks B) After 3 to 4 weeks C) After 4 to 5 weeks D) After 6 to 12 weeks
Ans: D Feedback: Live attenuated vaccines should be administered to clients after 6 to 12 weeks of administration of immune globulin preparation. MMR vaccine, being a live attenuated vaccine, should be administered to the child after 6 to 12 weeks, as the child has received immune globulin for a snake bite. Vaccinations containing live organisms are not administered within 6 to 12 weeks of immune globulin administration because antibodies in the globulin preparation may interfere with the immune response to the vaccination. To obtain an effective immune response to vaccination, the live vaccine has to be administered 14 to 30 days before or 6 to 12 weeks after immune globulin administration.
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. Which of the following kinds of immunity is the nurse referring to? A) Active immunity B) Cell-mediated immunity C) Humoral immunity D) Passive immunity
Ans: D Feedback: 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.
A nurse is required to administer a varicella vaccine to a female client planning to start a family. How long after the vaccination should the nurse instruct the client to wait before getting pregnant? A) 2 weeks B) 4 weeks C) 8 weeks D) 12 weeks
Ans: D Feedback: The nurse should instruct the client to wait at least 12 weeks (3 months) before getting pregnant after receiving measles, mumps, rubella, and varicella vaccines. Measles, mumps, rubella, and varicella vaccines are contraindicated in pregnancy, especially in the first trimester, because of the danger of birth defects in the infant. Following vaccination with these agents, the client is advised to wait for 12 weeks before getting pregnant.
The parents of a child who is recovering from chickenpox tell the nurse that they gave the child aspirin for his fever. The nurse would be alert to the development of which of the following? A) Lymphoma B) Angioneurotic edema C) Acute renal failure D) Reye's syndrome
Ans: D Feedback: When salicylates are administered along with the varicella vaccine, there is an increased risk of development of Reye's 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.
