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 D

Explanation

Rationale for Choice A:

While maintaining normal body temperature is important for overall health, it's not the most immediate priority in a patient with fluid volume deficit due to ongoing bleeding. Fluid volume status takes precedence over temperature regulation in this context.

Hypovolemia can lead to hypothermia, but addressing the fluid deficit directly will also help stabilize temperature.

Focusing solely on temperature could delay crucial interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice B:

An intact surgical incision is essential for proper wound healing and prevention of infection. However, in the context of active bleeding, it's not the priority outcome.

Maintaining adequate fluid volume is crucial to ensure perfusion of tissues, delivery of oxygen and nutrients, and proper organ function—all of which take precedence over incision integrity in this acute situation.

Addressing the fluid deficit will indirectly support wound healing by promoting tissue perfusion and reducing the risk of complications.

Rationale for Choice C:

Patient education is important, but it's not the most immediate priority in a patient with active bleeding and fluid volume deficit.

The patient's ability to comprehend and implement measures to reduce fluid loss may be compromised due to the hypovolemic state and potential cognitive effects.

Focusing on patient education at this stage could delay essential interventions to address the fluid loss and potentially worsen the patient's condition.

Rationale for Choice D:

Urine output is a sensitive and reliable indicator of renal perfusion and overall fluid status. In a patient with fluid volume deficit, maintaining a urine output of at least 30 mL/hour is a key indicator that the kidneys are receiving adequate blood flow and that fluid volume is being restored.

This outcome directly addresses the fluid deficit and serves as a measurable goal for fluid replacement therapy.

It takes priority over other choices because it directly reflects the patient's fluid status and the effectiveness of interventions to address the bleeding and fluid loss.

A. A superficial 3-inch x 3-inch abrasion has no active bleeding, drainage, or debris. B. The 4-inch incision edges are well approximated with intact sutures. C. An ulcerated 3-inch x 1-inch area has thick yellow slough present in the center. D. The incision is 5 inches long x 1 inch deep x 1 inch wide with granulation tissue present.

Correct Answer is B

Explanation

Choice A rationale:

A superficial abrasion heals by secondary intention, not primary intention.

In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.

The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.

Choice C rationale:

The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.

Choice D rationale:

The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.

Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.

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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

Naxlex Comprehensive Predictor Exams

What is the priority outcome for a patient with the nursing diagnosis of fluid volume deficit related to ongoing postoperative bleeding?

Correct Answer is D

Explanation

Which assessment charting indicates that the wound is healing by primary intention?

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?