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:
Anemia is not a complication typically associated with shingles. Shingles is caused by the varicella-zoster virus, and it primarily affects the nerves and skin, leading to a painful rash.
Choice B rationale:
Migraine headaches are not directly related to shingles. Shingles affects sensory nerves and typically presents with localized pain and a rash along the affected nerve's pathway.
Choice C rationale:
The nurse should monitor for postherpetic neuralgia in this client. Postherpetic neuralgia is a common complication of shingles that involves persistent and severe pain in the area where the rash was present. It occurs due to nerve damage caused by the virus, and the pain can last for weeks to months after the rash has healed.
Choice D rationale:
Asthma is not a complication associated with shingles. Shingles is a viral infection that primarily affects the skin and nerves and does not involve the respiratory system.
Correct Answer is C
Explanation
Choice A rationale:
Complete Blood Count (CBC) is not useful in confirming the diagnosis of chickenpox. CBC provides information about the number and types of blood cells but is not specific to chickenpox diagnosis.
Choice B rationale:
Stool culture is not relevant in confirming the diagnosis of chickenpox. Stool culture is used to identify gastrointestinal infections, and it is not associated with chickenpox.
Choice C rationale:
Tzanck smear and viral culture from vesicle fluid are useful in confirming the diagnosis of chickenpox. Tzanck smear involves taking a sample from the vesicle and staining it to identify multinucleated giant cells, which are characteristic of varicella-zoster virus (VZV) infection. Viral culture involves growing the VZV in a lab to confirm the presence of the virus.
Choice D rationale:
Urinalysis is not relevant in confirming the diagnosis of chickenpox. Urinalysis is used to assess kidney function and detect urinary tract infections, but it does not help in diagnosing chickenpox.
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