Nokea
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.
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The parents of a child who is recovering from chickenpox tell the nurse that they gave the child aspirin for his fever. The nurse would be alert to the development of which of the following?
- A. Lymphoma
- B. Angioneurotic edema
- C. Acute renal failure
- D. Reye's syndrome
Correct Answer: D
Rationale: Aspirin use during chickenpox increases the risk of Reye's syndrome.
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.
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.
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.
Which of the following is an example of artificially acquired active immunity? Select all that apply.
- A. An individual 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: B,D,E
Rationale: Artificially acquired active immunity occurs when an individual is given a killed or weakened antigen, which stimulates the formation of antibodies against the antigen. The antigen does not cause the disease, but the individual still manufactures specific antibodies against the disease.