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
Explanation
Choice A rationale:
The primary infection of VZV occurs through respiratory droplets, not when a person comes into contact with them. The virus is highly contagious and spreads through respiratory secretions.
Choice B rationale:
Reactivation of VZV in the nerve cells leads to the onset of shingles, not chickenpox. Chickenpox is the primary infection, and after recovery, the virus remains dormant in nerve cells and can reactivate as shingles later in life.
Choice C rationale:
The incubation period of VZV for chickenpox ranges from 10 to 21 days, which is accurate information.
Choice D rationale:
The risk of transmission during reactivation (shingles) is higher than during primary infection (chickenpox) Shingles can cause the development of vesicles containing the virus, which can be contagious if someone comes into direct contact with the fluid from the vesicles. Primary chickenpox, on the other hand, spreads through respiratory droplets and is more widespread during the initial infection.
Correct Answer is C
Explanation
Choice A rationale:
(Incorrect) The herpes zoster vaccine (shingles vaccine) is not administered to patients with chickenpox. The vaccine is recommended for those aged 50 years and older to prevent shingles in individuals who have previously had chickenpox.
Choice B rationale:
(Incorrect) Encouraging contact with immunocompromised individuals is not appropriate when caring for a patient with chickenpox. Immunocompromised individuals are more susceptible to severe complications from the varicella-zoster virus, so close contact should be avoided.
Choice C rationale:
(Correct) Using cool compresses is an essential comfort measure for patients with chickenpox. Cool compresses can help soothe the itching and discomfort caused by the chickenpox rash.
Choice D rationale:
(Incorrect) Providing educational materials only to the patient is not sufficient. It is important for the nurse to educate the patient's family members or caregivers about chickenpox precautions and care to prevent further transmission of the virus.
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