The nurse is caring for a patient with a puncture wound.
How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

10 years

1 year

5 years

2 years

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale:

Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani. The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc. Anyone can get tetanus, but the disease is particularly common and serious in newborn babies and pregnant women who have not been sufficiently immunized with tetanus-toxoid-containing vaccines.

To ensure that there is adequate antitoxin to neutralize tetanus toxin in the case of a tetanus-prone injury, a booster dose is advised if it has been longer than 10 years since the last tetanus vaccine dose. This is because a single dose of tetanus toxoid produces a rapid anamnestic response. Therefore, if a patient with a puncture wound has not received a tetanus toxoid vaccination in the last 10 years, they would require an additional injection before being discharged from the emergency department.

Choice B rationale:

While it might seem prudent to administer a tetanus toxoid vaccination every year, this is not necessary according to current medical guidelines. Over-vaccination could potentially lead to an increased risk of adverse reactions without providing additional benefits. Therefore, a tetanus toxoid vaccination is not required every year.

Choice C rationale:

A 5-year interval for tetanus toxoid vaccination is not the standard recommendation for general population. However, in some specific cases, such as when indicated for wound management, a tetanus toxoid–containing vaccine might be administered if ≥5 years have elapsed since the previous receipt of any tetanus toxoid–containing vaccine.

Choice D rationale:

A 2-year interval for tetanus toxoid vaccination is not the standard recommendation. The tetanus toxoid vaccination provides protection for a much longer period, and therefore, it is not necessary to administer the vaccine every 2 years.

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Correct Answer is A

Explanation

Choice A rationale:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

A. The patient follows a lactose-free diet. B. The patient has a history of thrombocytopenia. C. The patient has several herniated lumbar disks. D. The patient is allergic to latex and strawberries.

Correct Answer is B

Explanation

Choice A rationale:

A lactose-free diet does not contraindicate acupuncture therapy. Lactose intolerance is a digestive condition that does not affect blood clotting or the ability to receive acupuncture safely.

Acupuncture needles are very fine and do not typically cause bleeding. Even if minor bleeding occurs, it is not a concern for individuals without bleeding disorders.

Therefore, a lactose-free diet does not pose a risk for acupuncture.

Choice B rationale:

Thrombocytopenia is a condition characterized by a low platelet count. Platelets are essential for blood clotting. Acupuncture involves the insertion of needles into the skin. This can cause minor bleeding, even when performed correctly.

In individuals with thrombocytopenia, even minor bleeding can be difficult to control and may lead to excessive bruising or hematoma formation.

Therefore, thrombocytopenia is a contraindication to acupuncture therapy due to the increased risk of bleeding complications.

Choice C rationale:

Herniated lumbar disks are a common condition that can cause back pain. Acupuncture is often used to treat back pain, including pain caused by herniated disks.

Studies have shown that acupuncture can be effective in reducing pain and improving function in patients with herniated disks.

Therefore, the presence of herniated lumbar disks does not contraindicate acupuncture therapy.

Choice D rationale:

Latex and strawberry allergies are not contraindications to acupuncture therapy. Acupuncture needles are typically made of stainless steel, which does not contain latex.

Additionally, acupuncture does not involve the use of strawberries or any other substances that are common allergens. Therefore, latex and strawberry allergies do not pose a risk for acupuncture.

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The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?

Nursing Test Bank

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Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

Correct Answer is A

Explanation

Which assessment finding indicates that the patient is not a candidate for acupuncture therapy?

Correct Answer is B

Explanation

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The nurse is caring for a patient with a puncture wound.
How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?