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Difficulty: MediumData Collection Techniques

A practical nurse (PN) is reviewing the health history intake data for four pediatric clients who are scheduled to receive the live attenuated measles, mumps, and rubella (MMR) vaccine today. Which client's data indicates a contraindication that requires the PN to withhold the immunization and notify the healthcare provider?

  1. A 5-year-old client who is currently receiving systemic chemotherapy for acute lymphoblastic leukemia.Answer
  2. B
    A 15-month-old client who is not yet able to walk independently without support.
  3. C
    A 4-year-old client who has a mild upper respiratory infection with a temperature of 99.8°F (37.7°C).
  4. D
    A 6-year-old client whose parent reports the child has an allergy to eggs that causes mild hives.

Answer

The 5-year-old client who is currently receiving systemic chemotherapy for acute lymphoblastic leukemia.
Live attenuated vaccines, such as the MMR vaccine, contain a weakened form of the virus. In a healthy immune system, this safely stimulates an immune response. However, in clients who are severely immunocompromised, such as those receiving systemic chemotherapy for leukemia, the weakened virus can replicate uncontrollably and cause a severe, life-threatening infection. Recognizing this during data collection is critical, and the PN must withhold the vaccine and report the finding.

Step-by-Step Solution

1
Identify the nature of the scheduled medication.
The MMR vaccine is a live attenuated virus vaccine.
Understanding the vaccine type is essential to identify specific contraindications.
2
Evaluate the clinical intake data of each client against known contraindications for live vaccines.
The client receiving systemic chemotherapy is severely immunocompromised.
Live vaccines carry a risk of causing severe, uncontrolled infection in clients with compromised immune systems.
3
Determine the appropriate nursing action based on the practical nurse's scope of practice.
The PN must recognize the contraindication, withhold the MMR vaccine for the immunocompromised client, and report this finding to the provider.
Administering a live vaccine to an immunocompromised client is a major safety risk that must be prevented.

Key Concept

Data collection for live vaccine contraindications
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Topics

Data Collection Techniques

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