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:
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.
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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