Nokea
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.
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When describing humoral immunity to a group of nursing students, which of the following would the instructor most likely include? Select all that apply.
- A. B lymphocytes are involved.
- B. An antigen-antibody response occurs.
- C. An immunity that is independent of cell-mediated immunity occurs.
- D. T lymphocytes are activated.
- E. The immunity protects the body against bacterial, viral, and fungal infections.
Correct Answer: A,B
Rationale: Humoral immunity involves B lymphocytes and antigen-antibody responses, protecting against bacterial and viral infections.
When teaching a client who is receiving cytomegalovirus immune globulin, the nurse would alert the client to the possibility of which of the following? Select all that apply.
- A. Urticaria
- B. Angioedema
- C. Constipation
- D. Headache
- E. Chills
Correct Answer: A,B,D,E
Rationale: Common adverse reactions to cytomegalovirus immune globulin include urticaria, angioedema, headache, and chills. Constipation is not typical.
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.
Vaccines containing live organisms are not administered to clients taking which of the following drugs as insufficient numbers of antibodies are produced to prevent the disease because these drugs suppress the immune system? Select all that apply.
- A. Methylprednisolone (Medrol)
- B. Ciprofloxacin (Cipro)
- C. Prednisolone (Orapred)
- D. Paclitaxel (Taxol)
- E. Vincristine (Oncovin)
Correct Answer: A,C,D,E
Rationale: Live vaccines are contraindicated with corticosteroids (methylprednisolone, prednisolone) and antineoplastic drugs (paclitaxel, vincristine) due to immune suppression.
A nursing instructor is describing the concept of immunity. The instructor determines that the teaching was successful when the students identify that cell-mediated immunity protects the body against what type of infections? Select all that apply.
- A. Viral
- B. Protozoal
- C. Fungal
- D. Bacterial
- E. Helminth
Correct Answer: A,C,D
Rationale: Cell-mediated immunity protects the body against viral, bacterial, and fungal infections.