A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?

The client had a local reaction from a previous immunization

The client reports having diarrhea this morning

The client is at 9 weeks of gestation

The client reports an allergy to penicillin.

Answer and Explanation

The Correct Answer is C

A. The client had a local reaction from a previous immunization. A mild local reaction, such as redness or swelling at the injection site, is not a contraindication to receiving the MMR vaccine. These reactions are common and typically resolve without complications. Only severe allergic reactions, such as anaphylaxis, would warrant withholding the vaccine.

B. The client reports having diarrhea this morning. Mild illnesses, such as diarrhea or the common cold, do not contraindicate vaccination. The MMR vaccine can be safely administered as long as the client does not have a moderate to severe illness with fever. Delaying immunization due to minor illnesses could lead to unnecessary gaps in vaccine coverage.

C. The client is at 9 weeks of gestation. The MMR vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal harm. Pregnant individuals should wait until after delivery to receive the vaccine. If a client of childbearing age is vaccinated, they should be advised to avoid pregnancy for at least 4 weeks following immunization to reduce the risk of congenital rubella syndrome.

D. The client reports an allergy to penicillin. A penicillin allergy is not a contraindication for the MMR vaccine. The MMR vaccine does not contain penicillin or related antibiotics. Severe allergic reactions to vaccine components, such as neomycin or gelatin, would be more relevant contraindications. Clients with a penicillin allergy can safely receive the MMR vaccine without concern.

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Correct Answer is D

Explanation

A. Alprazolam. Alprazolam, a benzodiazepine, is metabolized in the liver and can accumulate in clients with chronic liver disease, increasing the risk of sedation, confusion, and hepatic encephalopathy. Benzodiazepines should be used cautiously or avoided in clients with liver impairment.

B. Rotavirus vaccine. The rotavirus vaccine is a live, attenuated vaccine given to infants to prevent severe diarrhea caused by rotavirus infection. It is not recommended for adults, including those with chronic liver disease, as it is not indicated for their age group or condition.

C. Niacin. Niacin is used to lower cholesterol and treat vitamin B3 deficiency, but it can cause hepatotoxicity, especially in high doses. In clients with chronic liver disease, niacin may worsen liver function, making it an inappropriate choice unless absolutely necessary and closely monitored.

D. Hepatitis A vaccine. Clients with chronic liver disease are at higher risk of severe complications from hepatitis A infection. Vaccination provides protection against hepatitis A, which can cause acute liver failure in individuals with pre-existing liver disease. It is recommended to prevent further liver damage and protect overall health.

A. Increase fluid intake B. Decrease sodium intake C. Eat foods high in potassium D. Take the medication 1 hr before meals.

Correct Answer is A

Explanation

A. Increase fluid intake. Clients taking lithium should increase fluid intake to 2-3 litres per day to prevent dehydration and maintain proper lithium excretion. Lithium is excreted by the kidneys, and dehydration can lead to toxic accumulation in the body. Adequate hydration also helps reduce the risk of side effects such as nephrotoxicity and lithium-induced polyuria.

B. Decrease sodium intake. Clients should not decrease sodium intake while on lithium. A low-sodium diet increases lithium reabsorption in the kidneys, leading to a higher risk of lithium toxicity. Instead, sodium intake should remain consistent, and clients should avoid excessive sodium restriction or sudden dietary changes.

C. Eat foods high in potassium. Potassium levels are not significantly affected by lithium therapy. While potassium is essential for overall health, increasing potassium intake is not a specific recommendation for lithium users. Potassium-rich foods are more relevant for clients taking diuretics (e.g., furosemide) or cardiac medications like digoxin.

D. Take the medication 1 hr before meals. Lithium is typically taken with food or milk to minimize gastrointestinal irritation. Taking it on an empty stomach can increase the likelihood of nausea and gastric discomfort, making it harder for clients to adhere to treatment. Clients should follow their provider’s instructions regarding meal timing.

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A nurse in a clinic is preparing to administer the measles, mumps, rubella (MMR) vaccine to a client. Which of the following findings should indicate to the nurse that the client has a contraindication for the MMR vaccine?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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