NCLEX-RNSafety and Infection Prevention and ControlMedium
A nurse is preparing to administer an influenza vaccine via intramuscular injection to an adult client. The client reports a severe allergy to eggs, stating, 'Every time I eat eggs, my throat swells, and I have trouble breathing.' Which action should the nurse take next?
- AAdminister the vaccine in a facility where emergency resuscitation equipment is readily available.
- BAdminister the vaccine as prescribed, observing the client closely for 30 minutes post-injection.
- CWithhold the vaccine and notify the healthcare provider of the client's allergy.
- DExplain to the client that modern influenza vaccines are safe for individuals with egg allergies and proceed with administration.
Show answer & explanationAnswer & explanation
Correct answer: C. Withhold the vaccine and notify the healthcare provider of the client's allergy.
A severe allergic reaction to eggs is a contraindication for many influenza vaccines. The nurse must prioritize client safety by withholding the medication and escalating the concern to the healthcare provider for further assessment and alternative options. Administering the vaccine could lead to a life-threatening anaphylactic reaction.
Why the other options are wrong
- A. While emergency equipment is always good, administering a contraindicated vaccine is still unsafe and should be avoided.
- B. Administering the vaccine with a severe egg allergy history is unsafe and could lead to anaphylaxis.
- D. Some influenza vaccines are egg-free or contain minimal egg protein, but a severe allergy warrants caution and provider consultation, not an assumption of safety.
Vaccine Contraindication
A condition or factor that serves as a reason to withhold a particular medical treatment due to the harm that it would cause the patient.
- Severe allergic reaction to a vaccine component is a contraindication.
- Healthcare provider consultation is required for contraindications.
- Client safety is the top priority in medication administration.
Memory trick: Egg-cellent safety: Check before you inject!