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A 12-month-old infant has received an MMR II (measles, mumps, and rubella virus vaccine), and her mother calls the clinic that afternoon to ask about helping her fussy infant to 'feel better.' What will the nurse suggest?
- A. Apply ice packs
- B. Apply warm compresses
- C. Observe the site for further swelling
- D. Bring the infant in to the emergency department for an immediate exam
Correct Answer: B
Rationale: Applying warm compresses to the injection site and using acetaminophen (not aspirin, which carries the risk for Reye's syndrome) should help to relieve the discomfort. The other options are incorrect.
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A 45-year-old man has received a series of immunizing drugs in preparation for a trip to a developing country. Within hours, his wife brings him to the emergency department because he has developed edema of the face, tongue, and throat and is having trouble breathing. The nurse suspects that, based on the patient's history and symptoms, he is experiencing which condition?
- A. Serum sickness
- B. Cross-sensitivity
- C. Thrombocytopenic purpura
- D. Anaphylaxis
Correct Answer: D
Rationale: The symptoms of edema of the face, tongue, and throat along with difficulty breathing suggest an anaphylactic reaction, which is a severe allergic response that can occur after receiving immunizing drugs. Serum sickness is characterized by symptoms like fever, rash, and joint pain, typically appearing days to weeks after exposure. Cross-sensitivity refers to allergic reactions to related substances, and thrombocytopenic purpura involves bleeding issues due to low platelet counts, neither of which match the described symptoms.
A nurse is working in an immunization clinic. A new colleague asks, 'When is the first dose of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine given?' The nurse knows that this series is started at what age?
- A. At birth
- B. 6 weeks
- C. 3 months
- D. 1 year
Correct Answer: B
Rationale: The first dose of the DTaP vaccine series is given at 6 weeks of age. The other options are incorrect.
A health care worker will be receiving hepatitis B immunoglobulin, 0.6 mL/kg IM now and repeated in 30 days as part of hepatitis B prophylaxis after a needle stick accident. The patient weighs 242 pounds. Identify how many milliliters the patient will receive for each dose. (Record answer using one decimal place.)
Correct Answer: 6.6 Ml
Rationale: Convert pounds to kilograms: 242 ?· 2.2 = 110 kg. Calculate mL/kg: 0.6 mL/kg/dose ?? 110 kg = 6.6 mL/dose.
A patient is in the urgent care center after experiencing a black widow spider bite. The nurse prepares to give which product to treat this injury?
- A. Live vaccine
- B. Antivenins or antisera
- C. Tetanus immune globulin
- D. Active immunizing drug
Correct Answer: B
Rationale: Antivenins, also known as antisera, are used to prevent or minimize the effects of poisoning by poisonous snakes and spiders. They provide the person who has been bitten with the substance needed to overcome the effects of the venom.
The nurse is reviewing principles of immunization. What type of immunization occurs when antibodies pass from mother to infant during breastfeeding or through the placenta during pregnancy?
- A. Artificial active immunization
- B. Attenuating immunization
- C. Natural passive immunization
- D. Artificial passive immunization
Correct Answer: C
Rationale: Natural passive immunization occurs when antibodies are transferred from the mother to her infant in breast milk or through the bloodstream via the placenta during pregnancy. Artificial active immunization causes an antigen-antibody response and stimulates the body's defenses to resist any subsequent exposures. Artificial passive immunization is conferred by bypassing the host's immune system and injecting the person with antiserum or concentrated antibodies obtained from other humans or animals.