Nokea
When educating a group of nursing students on immunologic agents, the nurse refers to a substance that is attenuated (or weakened) but still capable of stimulating the formation of antitoxins. The nurse determines that the teaching was successful when the students identify this substance as which of the following?
- A. Antivenins
- B. Toxoids
- C. Vaccines
- D. Immune globulins
Correct Answer: B
Rationale: Toxoids are weakened toxins that stimulate antitoxin formation.
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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 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 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).
Human immune globulin intravenous (IGIV) products have been associated with renal problems. The nurse understands that which clients should not receive IGIV? Select all that apply.
- A. Clients with diabetes mellitus
- B. Clients 65 years of age or older
- C. Clients receiving vancomycin
- D. Clients with pre-existing renal disease
- E. Clients receiving cephalexin
Correct Answer: A,B,C,D
Rationale: IGIV is contraindicated in clients with diabetes, those 65 or older, those with pre-existing renal disease, or those receiving nephrotoxic drugs like vancomycin.
After teaching a class to a group of nursing students about immunity, the instructor determines that the teaching was successful when the students identify which of the following as an example of passive 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 botulism immune globulin (BabyBIG) for the treatment of infant botulism
- C. An individual who is exposed to pertussis for the first time and has no immunity to the disease
- D. Administration of Crotalidae polyvalent immune Fab (CroFab) for the treatment of mild to moderate North American rattlesnake bites
- E. Administration of the rubella vaccine to an individual who has no immunity to the disease
Correct Answer: B,D
Rationale: Passive immunity occurs when immune globulins or antivenins are administered, providing ready-made antibodies from another human or animal.