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After receiving a vaccination for a communicable disease, the patient was asked to return in 2 to 3 weeks to get an antibody titer and asks why blood testing can’t be done immediately. How should the RN (registered nurse) respond?

 

A.

It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration.

B.

The laboratory ran out of blood specimen tubes and is unable to perform the test today.

C.

It takes about 14 days to develop antigens and immunity to the disease after vaccine administration.

D.

After receiving the vaccine, you might transmit the communicable disease to the laboratory.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.

 

Choice B rationale

 

The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.

 

Choice C rationale

 

It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.

 

Choice D rationale

 

After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.


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Correct Answer is A

Explanation

Choice A rationale

Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.

Choice B rationale

Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.

Choice C rationale

Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.

Choice D rationale

Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

Correct Answer is A

Explanation

Choice A rationale

Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.

Choice B rationale

Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.

Choice C rationale

Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.

Choice D rationale

Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.

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