Nokea
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
Correct Answer: A
Rationale: Immediate hypersensitivity reactions to antivenins typically occur within 30 minutes.
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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
Correct Answer: B
Rationale: Acute Pain is likely due to injection site discomfort.
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
Correct Answer: B
Rationale: Toxoids are weakened toxins that stimulate antitoxin formation.
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
Correct Answer: A,D,E
Rationale: Antivenins provide passive, transient protection from bites by black widow spiders, rattlesnakes, copperhead snakes, cottonmouth snakes, and coral snakes.
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 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
Correct Answer: B,C,E
Rationale: Vaccinations for cholera, diphtheria, and Lyme disease are recommended for travel to endemic areas.