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 D
Explanation
Choice A rationale:
Pregnant women should receive the Tdap vaccine during each pregnancy. This is a correct statement as vaccination during pregnancy helps provide protection to both the mother and the newborn against tetanus, diphtheria, and pertussis.
Choice B rationale:
The recommended vaccination schedule for adults includes a single dose of Tdap (tetanus, diphtheria, and acellular pertussis) vaccine, followed by a Td (tetanus and diphtheria) booster every 10 years. Three doses of DTP vaccine during adulthood are not part of the recommended schedule.
Choice C rationale:
Tetanus prophylaxis should be given to patients with all types of wounds, not just severe wounds. This statement is incorrect.
Choice D rationale:
The Tdap vaccine is not administered every 5 years during adulthood. As mentioned earlier, adults receive a single dose of Tdap and then a Td booster every 10 years.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should recommend applying calamine lotion to soothe and dry the chickenpox lesions. Calamine lotion has a soothing effect on the skin and can help reduce the itching associated with chickenpox. It also helps to dry out the lesions, which may aid in the healing process. However, it is essential to advise the family not to apply calamine lotion on open sores or areas with broken skin to avoid potential irritation.
Choice B rationale:
Giving aspirin to a child with chickenpox is not recommended. Aspirin has been associated with an increased risk of Reye's syndrome in children with viral infections, including chickenpox. Reye's syndrome is a rare but potentially life-threatening condition that affects the brain and liver.
Choice C rationale:
Antiviral drugs, such as acyclovir, are often prescribed for severe cases of chickenpox or for individuals at high risk of complications. These drugs can help shorten the duration of the illness and reduce the severity of symptoms. They are not to be avoided to prevent side effects, as the benefits generally outweigh the potential risks.
Choice D rationale:
Allowing the child to play outside may not be the best approach to distract them from itching. It is crucial to prevent the child from scratching the rash to avoid secondary bacterial infections and scarring. Engaging the child in indoor activities and providing distractions that do not involve scratching would be a safer approach.
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