Nokea
A nurse should screen clients of childbearing age for pregnancy as the administration of which of the following vaccines is contraindicated during pregnancy? Select all that apply.
- A. Influenza
- B. Varicella
- C. Measles
- D. Mumps
- E. Rubella
Correct Answer: B,C,D,E
Rationale: Measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy due to potential birth defects.
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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.
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 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 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 is preparing to administer an immunologic drug that produces active immunity. Which of the following might the nurse be administering? Select all that apply.
- A. Vaccines
- B. Antibodies
- C. Toxoids
- D. Antigens
- E. Immune globulin
Correct Answer: A,C
Rationale: Both vaccines and toxoids are administered to stimulate the body's immune response to specific antigens or toxins, producing active immunity.