Nokea
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 funds
Correct Answer: A,B,D
Rationale: Acetaminophen, rest, and compresses help manage vaccine-related pain.
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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).
Correct Answer: A,C,D
Rationale: Globulins are proteins containing antibodies, can be obtained from human or animal blood, and provide passive immunity with rapid onset but short duration (1 to 3 months).
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
Correct Answer: D
Rationale: Clients should wait 12 weeks after varicella vaccination before getting pregnant due to potential birth defects.
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
Correct Answer: C,E
Rationale: Allergies to gelatin or neomycin are contraindications for measles, mumps, rubella, and varicella vaccines.
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.
Correct Answer: A,B,C,D,E
Rationale: Parental education includes risks of diseases, benefits of immunization, next vaccination date, adverse reactions, and the need to bring immunization records.
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
Correct Answer: A,C
Rationale: Both vaccines and toxoids are administered to stimulate the body's immune response to specific antigens or toxins, producing active immunity.