Nokea
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.
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A client comes to the clinic and tells the nurse that close family members are suspected of having pulmonary tuberculosis. Which of the following would the nurse recommend as a preventative measure?
- A. MMR vaccine
- B. DPT vaccine
- C. BCG vaccine
- D. IPV vaccine
Correct Answer: C
Rationale: BCG vaccine is used to prevent tuberculosis in high-risk populations.
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 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.
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.
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.