Nokea
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.
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After teaching a group of nursing students about the various immunologic drugs, the instructor determines that the teaching was successful when the students identify which of the following as a viral vaccine? Select all that apply.
- A. Haemophilus influenza type B conjugate
- B. Typhoid
- C. Mumps
- D. Avian influenza
- E. Rabies
Correct Answer: C,D,E
Rationale: Mumps, avian influenza, and rabies are viral vaccines.
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.
Several clients have come to the clinic for immunizations. When reviewing their medical records, the nurse identifies which of the following as a contraindication for the administration of vaccines and toxoids? Select all that apply.
- A. Acute nonfebrile illness
- B. Leukemia
- C. Chronic prednisone therapy
- D. HIV
- E. Clients older than 70 years of age
Correct Answer: B,C,D
Rationale: Vaccines and toxoids are contraindicated in leukemia, immunosuppressive conditions like HIV, and chronic prednisone therapy.
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.
A nurse is caring for a client who has been bitten by a coral snake. Which of the following would the nurse expect to administer to this client?
- A. Antivenin
- B. Toxoid
- C. Vaccine
- D. Immune globulins
Correct Answer: A
Rationale: Antivenin is used for passive protection against coral snake venom.