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 ["B","D"]
Explanation
Choice B rationale:
Bell's palsy is a known complication of shingles (herpes zoster) The varicella-zoster virus (VZV), which causes chickenpox, remains dormant in the body and can reactivate as shingles later in life. Shingles can affect the facial nerve, leading to Bell's palsy, characterized by facial muscle weakness or paralysis on one side of the face.
Choice D rationale:
Postherpetic neuralgia is another complication associated with shingles. It is a persistent, severe pain that continues after the rash has healed, caused by nerve damage during the shingles infection. Choices A, C, and E rationales: Congestive heart failure (choice A), chronic obstructive pulmonary disease (choice C), and acute pancreatitis (choice E) are not directly related to shingles. These conditions are not commonly known as complications of shingles or the varicella-zoster virus infection.
Correct Answer is D
Explanation
Choice A rationale:
Monitoring vital signs, fluid intake, and output is important for assessing the client's overall health and hydration status, but it does not specifically address preventing the transmission of the virus.
Choice B rationale:
Providing comfort measures like cool compresses and loose clothing can help alleviate symptoms and discomfort, but it does not directly address preventing the transmission of the virus.
Choice C rationale:
Encouraging oral hygiene and a soft diet is essential for managing the client's symptoms and promoting healing, but it does not focus on preventing the spread of the virus to others.
Choice D rationale:
Isolating the patient until all lesions are crusted over is a crucial nursing intervention to prevent transmission of the chickenpox virus. Chickenpox is highly contagious, primarily spread through respiratory droplets and contact with the fluid from the skin lesions. By isolating the patient until all lesions have crusted over, the risk of spreading the virus to others is significantly reduced.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.