A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?

A pregnant parent

Receiving treatment for leukemia

Taking acetaminophen for mild discomfort

An allergy to eggs

Answer and Explanation

The Correct Answer is B

A. A pregnant parent. A child can receive the varicella vaccine even if the parent is pregnant. While the varicella vaccine is a live attenuated vaccine, the vaccinated child does not pose a significant risk of transmission to others. The parent should avoid direct contact with the vaccinee's rash if one develops, but this is not a contraindication to immunization.

B. Receiving treatment for leukemia. Children undergoing treatment for leukemia often have weakened immune systems due to chemotherapy or radiation. The varicella vaccine is a live attenuated vaccine, meaning it contains a weakened form of the virus that could cause severe illness in immunocompromised individuals. These children should not receive live vaccines until their immune function improves and their healthcare provider approves vaccination.

C. Taking acetaminophen for mild discomfort. Acetaminophen is an over-the-counter pain reliever and fever reducer that does not interfere with the efficacy or safety of the varicella vaccine. There is no evidence that mild analgesic use before or after vaccination affects immune response, so it is not a reason to withhold the immunization.

D. An allergy to eggs. Unlike some influenza and yellow fever vaccines, the varicella vaccine is not produced using egg-based components. An egg allergy is not a contraindication to receiving the varicella vaccine, as it does not contain egg proteins.

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Correct Answer is B

Explanation

A. Restart the infusion in the other extremity. While the IV infusion will need to be restarted in a new site, the priority after discontinuing the infusion is to manage the complications of IV infiltration. Restarting the infusion should be done after addressing the swelling and discomfort in the affected limb.

B. Elevate the extremity. Elevating the extremity reduces swelling and promotes fluid reabsorption following an IV infiltration. This helps minimize pain, tissue damage, and further complications, such as compartment syndrome. It is the next priority action after stopping the infusion.

C. Remove the catheter. The catheter should already be removed when the infusion is discontinued due to suspected infiltration. Keeping it in place could worsen tissue swelling and damage. If the catheter has not been removed yet, doing so is essential, but managing swelling and discomfort remains the priority after removal.

D. Apply warm, moist compresses to the site. Warm compresses are typically used for extravasation of non-vesicant solutions to promote circulation and absorption. However, in cases of severe infiltration or swelling, cold compresses may be used initially to reduce inflammation before applying warmth. The priority action is elevation, followed by applying appropriate compresses based on facility protocol.

A. Excoriation B. Firmness C. Ulceration D. Bleeding

Correct Answer is B

Explanation

A. Excoriation. Excoriation (skin abrasion or scratching) does not indicate a positive tuberculin skin test. A positive reaction is determined by induration (firm swelling) rather than skin irritation or superficial damage. Scratching the site can cause redness, but this is not a diagnostic sign of tuberculosis exposure.

B. Firmness. A positive tuberculin skin test is identified by the presence of induration (firm, raised swelling) at the injection site, which is measured in millimeters. The size of induration considered positive depends on the client’s risk factors. For example, ≥5 mm is positive in immunocompromised individuals, ≥10 mm in high-risk populations, and ≥15 mm in individuals with no risk factors.

C. Ulceration. Ulceration is not a typical reaction to a tuberculin skin test. If ulceration occurs, it may indicate improper injection technique, irritation, or an allergic reaction, rather than a true positive result. The test should be repeated in such cases.

D. Bleeding. Minor pinpoint bleeding at the injection site may occur due to the needle puncture but does not indicate a positive result. The key indicator of a positive test is the presence of measurable induration, not redness, bruising, or bleeding.

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A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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