The nurse in the emergency department phones to tell you that J.O.'s immunization status could not be
determined when he arrived, so no tetanus immunization was given.
When you ask J.O. the date of his last
tetanus shot, you find out that he was born and raised in Colombia and immigrated to the united States
5 years ago. He does not know whether he has ever had a tetanus shot. You inform the physician, and he
orders diphtheria/tetanus toxoid 0.5 mL IM and tetanus immune globulin (HyperTET) 250 units deep IM.
Why is J.O. getting two injections?
The first dose of diphtheria/tetanus toxoid is his general immunization against tetanus. A second
dose will be given in 1 to 2 months, and the third dose in 6 to 12 months. Thus, he will not be fully
immunized against tetanus for 6 to 12 months. HyperTET provides passive immunity to tetanus after
injury for those people who have not had a complete set of tetanus immunizations. HyperTET will
provide protection from tetanus during the current injury.
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Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
a. documents facts. b. documents how he/she feels about the care being provided. c. documents in a "block" fashion once per shift. d. double documents as often as possible in order to not miss anything.
While traveling throughout Asia, a young couple was exposed to many cultural experiences. One day, they were standing in line, and the person in front of them was clearly displaying signs of illness and had a pink or light red rash on his face with itchin
Their guide commented on a recent outbreak of rubella. Upon return to the United States, the couple found out they were pregnant. Upon arrival at the clinic, they are very concerned about their possible exposure to rubella. From this history, the nurse knows that this infant is at high risk for which of the following complications? Select all that apply. A) Blindness or cataracts B) Deafness C) Facial deformities like small palpebral fissures or thin vermillion border D) Short, flipper-like appendages E) Small outbreak of blisters around its eyes and mouth 2 weeks after delivery
While completing the cardiovascular system health history, a patient tells the nurse about using four pillows at night to sleep. The nurse will use this information to further assess which area?
A) Chest pain B) Shortness of breath C) Palpitations D) Edema
The nurse is caring for a 14-year-old girl with severe acne. She expresses sadness and distress about her appearance. How should the nurse respond?
A) "Are you using your medicine every day?" B) "Your condition will most likely improve in a year or two." C) "Many people feel this way; I know someone who can help." D) "If you have any scarring, you can undergo dermabrasion."