A client with a contaminated wound asks the nurse, "What does tetanus prophylaxis involve?" Which response by the nurse is accurate?
"Tetanus prophylaxis includes administering Td vaccine only if the wound is severe.”
"Tetanus prophylaxis involves giving TIG and Td vaccine depending on wound type and vaccination history.”
"Tetanus prophylaxis is not necessary if you received the DTP vaccine in childhood.”
"Tetanus prophylaxis consists of giving Td vaccine every 5 years to maintain immunity.”
The Correct Answer is B
Choice A rationale:
Administering the Td vaccine only if the wound is severe is not the correct response. Tetanus prophylaxis is recommended based on wound type and vaccination history, not just the severity of the wound.
Choice B rationale:
This is the correct response. Tetanus prophylaxis involves giving Tetanus Immunoglobulin (TIG) for immediate protection against tetanus toxin, along with the Tetanus and Diphtheria (Td) vaccine to promote long-term immunity. The decision to administer TIG and Td vaccine depends on the patient's wound type and their vaccination history.
Choice C rationale:
Tetanus prophylaxis is necessary even if the client received the DTP vaccine in childhood. The immunity from childhood vaccines may wane over time, and tetanus prophylaxis is recommended after potential exposure to the tetanus-causing bacteria.
Choice D rationale:
Giving the Td vaccine every 5 years is not the correct approach. The recommended schedule for Td booster doses is every 10 years, not every 5 years.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The varicella vaccine is not effective in preventing chickenpox. This statement is incorrect. The varicella vaccine is actually highly effective in preventing chickenpox. It contains a weakened form of the varicella-zoster virus, which stimulates the body's immune system to develop protection against the virus, reducing the risk of getting chickenpox.
Choice B rationale:
Serious adverse events from the vaccine are common. This statement is incorrect. Serious adverse events from the varicella vaccine are rare. Like all vaccines, there may be some mild side effects such as soreness at the injection site, fever, or a mild rash, but severe reactions are extremely uncommon.
Choice C rationale:
The vaccine has a high efficacy rate in preventing shingles. This statement is correct. The varicella vaccine not only helps prevent chickenpox but also reduces the risk of developing shingles later in life. Shingles is caused by the reactivation of the varicella-zoster virus, and the vaccine helps boost immunity to the virus, leading to a decreased likelihood of shingles.
Choice D rationale:
The vaccine is not recommended for pregnant women. This statement is generally correct. Pregnant women should avoid receiving the varicella vaccine because it is a live attenuated vaccine, and there is a theoretical risk of transmission to the fetus. If a woman is not immune to varicella and is planning to become pregnant, it's best to receive the vaccine before pregnancy.
Correct Answer is B
Explanation
Choice B rationale:
The symptoms described in the scenario, such as fever, headache, malaise, anorexia, pharyngitis, and the progression of a generalized pruritic rash from macules to papules to vesicles to pustules to crusts, are indicative of varicella-zoster virus (VZV) infection, commonly known as chickenpox. Otitis media (choice B) can be a complication of chickenpox, especially in children.
Choice A rationale:
Chronic kidney disease (choice A) is not a common complication of chickenpox. It is more commonly associated with conditions like diabetes and hypertension.
Choice C rationale:
Rheumatoid arthritis (choice C) is an autoimmune condition and is not a known complication of chickenpox.
Choice D rationale:
Type 2 diabetes (choice D) is not a common complication of chickenpox. Diabetes can increase the risk of infection, but it is not directly related to chickenpox.
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