Nokea
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
Correct Answer: A
Rationale: Antivenin is used for passive protection against coral snake venom.
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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
Correct Answer: A,C
Rationale: 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 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 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
Correct Answer: A,B,D,E
Rationale: Adverse reactions to influenza vaccine are usually mild, including chills, fever, muscle aches, and lethargy. Hypotension is not typically associated.
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
Correct Answer: A
Rationale: The dominant arm (right arm) is used to aid absorption.
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
Correct Answer: A,C,D
Rationale: Cell-mediated immunity protects the body against viral, bacterial, and fungal infections.