Nokea
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.
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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 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.
After administering the pneumococcal vaccine (Pneumovax) to a client, the nurse documents which of the following in the client's chart? Select all that apply.
- A. Date of next vaccination
- B. Vaccine lot number
- C. Vaccine expiration date
- D. Route and site of vaccine administration
- E. Name, address, and title of client vaccinated
Correct Answer: B,C,D
Rationale: Documentation includes vaccine lot number, expiration date, and route/site of administration.
A forest ranger arrives at a community clinic for prophylactic vaccination. Which of the following vaccines would be most important to be administered to the ranger?
- A. MMR vaccine
- B. Varicella vaccine
- C. Rotavirus vaccine
- D. Rabies vaccine
Correct Answer: D
Rationale: Rabies vaccine is critical for forest rangers due to potential animal exposure.
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.