A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a "bad reaction" to the last tetanus immunization. What is the most appropriate response by the nurse in this case?
A) Notify the health care provider that this immunization cannot be given.
B) Document that the patient is allergic to the tetanus vaccine.
C) Give the vaccine after explaining that adverse reactions are rare.
D) Ask the patient to describe the "bad reaction" to the vaccine in more detail.

Question

Quizplus · Accepted Answer

The nurse needs to collect more data about the reaction from the patient to determine the type of reaction experienced. The nurse is trying to assess the relationship between the "reaction" reported by the patient and an allergic reaction. The immunization should not be eliminated at this time. Additional facts are needed to determine the type of reaction the patient experienced. Documenting an allergy to the tetanus vaccine may be an error because there are insufficient data to make that determination at this time. Giving the vaccine may be an error if the patient is allergic to the vaccine and additional data indicates that may be the case.

A Nurse Is Interviewing a Male Patient Who Reports He