Nokea
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.
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A child is brought by his parents to the health care center for MMR vaccination. On taking the medical history, the nurse understands that the child had received an antivenin injection for a snake bite 2 days before. Which of the following is the most appropriate time period for administration of live vaccines to the confocal?
- A. After 1 to 2 weeks
- B. After 3 to 4 weeks
- C. After 4 to 5 weeks
- D. After 6 to 12 weeks
Correct Answer: D
Rationale: Live vaccines like MMR should be administered 6 to 12 weeks after antivenin to ensure effective immune response.
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.
Several clients have come to the clinic for immunizations. When reviewing their medical records, the nurse identifies which of the following as a contraindication for the administration of vaccines and toxoids? Select all that apply.
- A. Acute nonfebrile illness
- B. Leukemia
- C. Chronic prednisone therapy
- D. HIV
- E. Clients older than 70 years of age
Correct Answer: B,C,D
Rationale: Vaccines and toxoids are contraindicated in leukemia, immunosuppressive conditions like HIV, and chronic prednisone therapy.
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 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.