NCLEX-RNSafety and Infection Prevention and ControlEasy
A nurse is preparing to administer an influenza vaccine via intramuscular injection to an adult client. The client reports a previous severe allergic reaction to eggs. Which action should the nurse take?
- AAdminister the vaccine as prescribed, observing for 30 minutes post-injection.
- BAdminister a smaller dose of the vaccine and monitor closely for adverse effects.
- CWithhold the vaccine and consult with the healthcare provider for an alternative.
- DAdminister the vaccine after premedicating the client with an antihistamine.
Show answer & explanationAnswer & explanation
Correct answer: C. Withhold the vaccine and consult with the healthcare provider for an alternative.
A severe allergic reaction to eggs is a contraindication for some influenza vaccines, as they are often manufactured using egg-based technology. The nurse must prioritize client safety by withholding the vaccine and seeking further guidance.
Why the other options are wrong
- A. Administering the vaccine despite a known severe allergy is unsafe and could lead to anaphylaxis.
- B. Administering a smaller dose does not eliminate the risk of a severe allergic reaction in a client with a known allergy.
- D. Premedicating with an antihistamine does not prevent a severe allergic reaction and could mask initial signs of anaphylaxis.
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 allergies to vaccine components are contraindications.
- Live vaccines are contraindicated in immunocompromised individuals.
- Contraindications prioritize client safety over vaccination.
Memory trick: Safety First, Vaccines Later, if Risks are Greater.