Chapter 18
an elderly client has been given a tetanus-diphtheria (Td) booster after stepping on a rusty nail. Which statement indicates an understanding of vaccine schedules?
"I know that this booster is good for 10 years."
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."
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 is working with an 18-year-old client who recently immigrated and who did not receive childhood immunizations. The client is "catching up" on immunizations and is scheduled to receive a measles, mumps and rubella (MMR) vaccine today. What should the nurse teach the client about potential adverse effects?
"You might feel a bit unwell or get a slight fever after receiving your immunization."
A client has been prescribed prednisone 40 mg daily. What information about immunizations should the nurse include during client teaching?
"You should wait at least 3 months after chemotherapy to obtain a live vaccine immunization"
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.
(1) measles (2) varicella (3) poliomyelitis (4) Hepatitis B
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?
0.5mL
Which is an example of artificially acquired active immunity? (Select all that apply.)
1. Administration of the influenza vaccine to an individual who has no immunity to the disease. 2. Administration of the varicella vaccine to an individual who has no immunity to the disease. 3. Administration of the rubella vaccine to an individual who has no immunity to the disease.
Which is an example of naturally acquired active immunity? (Select all that apply.)
1. An individual who is exposed to chickenpox for the first time and has no immunity to the disease. 2. An individual who is exposed to pertussis for the first time and has no immunity to the disease.
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
A client was bitten by a poisonous snake. Which treatment would be most appropriate to administer?
Antivenin
What is the best source of information for current recommendations regarding immunizations and immunization schedules?
Centers for Disease Control and Prevention
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
A client who was bitten by a pit viper is to receive antivenin. What is the nurse's best action?
Establish IV access
Administration of the tetanus toxoid in adults involves two initial injections given four weeks apart, a booster injection given six months to a year later, and periodic injections thereafter. What is the recommended interval for the periodic injections for a 66 year old client ?
Every 10 years
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
A nurse is receiving post-exposure prophylaxis for hepatitis B. What would the nurse most likely receive?
Immune globulin
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
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
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
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
What would the nurse identify as a vaccine that is a toxoid?
Tetanus
The nurse is providing wellness information to a 50-year-old client who is employed as a paramedic. The client asks what, if any, vaccines the client should get. What is the nurse's best response?
Tetanus-diphtheria-pertussis; hepatitis B vaccine once; influenza vaccine annually
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
A nurse is teaching a group of clients about immunizations . What benefit of immunization should the nurse describe?
They provide the person with active immunity
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
A 70-year-old client is seen in the family practice clinic. Which vaccine should be administered to prevent herpes zoster?
Zoster vaccine
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
Which statements best indicates the client understands recommended vaccines following the 65th birthday?
a tetanus-diphtheria every 10 years, annual influenza vaccine, and a one-time administration of pneumococcal vaccine at 65 years of age
A client is to receive a physical prior to starting immune sera therapy. What would the nurse assess for?
adventitious breath sounds
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
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
A nurse is administering a mumps vaccine to an adolescent. Which medication should be available when administering an immunization?
epinephrine
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
When discussing vaccines in class, a student asks the instructor what an antitoxin is? What is an example of an antitoxin?
passive immunity
For what group of adults is pre-exposure immunization against hepatitis B recommended?
people who receive hemodialysis
What is a contraindication to an MMR booster for an adolescent female?
pregnancy
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
A client develops fever and arthralgia 4 days after the administration of tetanus toxoid. What reaction to the vaccine is this?
serum sickness
A school nurse is attempting to determine correct vaccine guidelines. What is the best source for current recommendations?
the Centers for Disease Control and Prevention
A client being vaccinated for measles asks the nurse about the contents of the vaccine. During the explanation, the nurse mentions a poisonous substance produced by some bacteria that is capable of stimulating antitoxin production. Which is the nurse referring to in the explanation?
toxin
The nurse must administer which to a client prior to exposure to the disease-causing organism in order for the client to be protected against the disease?
toxoids
To prevent meningococcal infections, the nurse would administer:
vaccine
