Which of the following groups should receive the pneumococcal vaccine (Pneumovax)? (Select ALL that apply.)
A. 8 month old baby with patent ductus arteriosus
B. 26 month old child with asthma receiving high-dose corticosteroids
C. 50 year old male with COPD
D. 68 year old female with hypertension, no other known medical conditions
E. 6 year old child receiving chemotherapy for lymphoma
B, C, D, E. Immunocompromised adults ages 19-64 years should receive Prevnarfollowed by Pneumovax at least 8 weeks later and then again years after the first Pneumovax dose.
Kate asks the pharmacist if her children should receive the annual influenza vaccination. She has a daughter, age 6 months, with no known illnesses, a daughter, 4 years, with asthma, and a son, 10 years, with ADHD. Which statement is correct?
A. Her 6 month old is too young to receive the influenza vaccine.
B. Her 6 month old should receive the nasal influenza vaccine.
C. Her four year old daughter should receive the influenza nasal mist.
D. None of the children should be receiving influenza vaccines until they are 12 years old.
E. Her 10 year-old son can receive the influenza nasal mist.
E. The influenza live nasal vaccine is for healthy people ages 2-49 years. Her son can get the nasal mist vaccine; the ADHD is not a contraindication. The older daughter cannot due to the asthma. The CDC prefers that all children 2-8 years of age should (preferably) be given the quadrivalent influenza vaccine.
Kate asks the pharmacist if her children will be protected from the scary H1N1 flu if they receive vaccine this year. Which of the following statements is true concerning the current influenza vaccine?
A. A current influenza vaccine (quadrivalent only) covers the H1N1 strain.
B. All of the current influenza vaccines cover the H1N1 strain.
C. The current influenza vaccine is bivalent; it covers two strains.
D. The H in H1N1 stands for haemophilus
E. The H1N1 is in a separate vaccine that is taken in addition to the influenza vaccine; a patient can request this at the pharmacy.
B. The current influenza vaccines are either trivalent (covers 3 strains) or quadrivalent (covers 4 strains). International experts convene to review which strains pose the largest threat and these are recommended for the upcoming vaccine production. The ones that are quadrivalent include an additional influenza type B, in addition to one type B and two type A's (one of which is H1N1) in the trivalent vaccine.
Kimberly asks the pharmacist if her children should receive the annual influenza vaccination. She states that every time she gets the flu shot, she gets the flu, but is worried about her kids getting a bad strain of the virus. She notes that her ten-year old daughter has an allergy to eggs; every time she eats scrambled eggs she gets an upset stomach. Otherwise, she has no known medical conditions except for a possible sensitivity to gluten. Kimberly home-schools her children. Which statements concerning the flu vaccine are correct?
A. You can get the flu from the flu shot, but the disease should be mild.
B. Unless children have a chronic disease, if they are home schooled they are not routinely vaccinated against influenza.
C. It is impossible to get influenza from the nasal flu vaccine.
D. Her daughter can receive the nasal FluMist vaccine.
E. Her daughter cannot receive MMR due to the allergy, but she can receive the influenza vaccine.
D. A severely immune-compromised patient could get influenza from the live nasal influenza vaccine, but no one can get influenza from the shot-the virus in the shot has been inactivated.
Vanessa is pregnant with her second child. She is in the second trimester. Vanessa is not sure what childhood vaccines she received and is positive she has not been vaccinated for anything in at least fifteen years, since that is when she left her parents home and lost her medical insurance. Which vaccine is recommended for Vanessa during her pregnancy? (SelectALL that apply.)
A. Influenza shot, at any time of the year
C. Measles, mumps and rubella
E. Influenza shot, if during flu vaccination season
B, E. The influenza vaccine is recommended during any stage of pregnancy. FluMist is a live vaccine; live vaccines are not used during pregnancy. If rubella vaccine (in MMR) was administered during pregnancy the baby would suffer severe birth defects.
A 12-month old child was hospitalized two months ago and received immuneglobulin. Which vaccine/s would be adversely affected by this treatment if administered today? (Select ALL that apply.)
A. Pneumococcal conjugate vaccine
B. Inactivated polio vaccine
C. Measles, mumps, rubella vaccine
D. Influenza vaccine, inactivated
E. Varicella vaccine
C, E. Live vaccines are affected by immuneglobulins.
A patient at your pharmacy has had diabetes and heart disease for over ten years. She remembers that she got the pneumococcal shot when she turned 50 years old and was diagnosed with diabetes. She is now 67 years old. Select the correct statement:
A. She needs both Prevnar 13 and Pneumovax 23.
B. She requires one dose of Pneumovax 23 but not Prevnar 13.
C. She requires one dose of Prevnar 13 and one dose of Pneumovax 23 at the same time.
D. She does not need a pneumococcal vaccine, but she does need to get the MMR vaccine.
E. She does not need the pneumococcal vaccine, but she should receive the FluMist vaccine annually.
Select the signs and symptoms of tetanus: (Select ALL that apply.)
A. Muscle rigidity
B. Painful muscle spasms
E. High fever
A, B, E. Tetanus (lockjaw) is a serious disease that causes painful tightening of the muscles, usually all over the body. It can lead to "locking" of the jaw so the victim cannot open his mouth or swallow. Tetanus leads to death in about 1 in 10 cases.
A 70 year old female enters the pharmacy and requests a vaccination against shingles (herpes zoster). Prior to administering the vaccine the following screening question must be asked:
A. Have you ever had a life-threatening allergic reaction to the antibiotic streptomycin?
B. Do you have a history of smoking?
C. Are you taking medication for thyroid disease?
D. Are you receiving more than 5 mg prednisone per day for at least the past two months?
E. Have you ever had a bad reaction to gelatin?
E. Shingles is a live vaccine and cannot be administered to severely immuno-compromised patients. Both shingles and chickenpox cannot be administered to anyone with a true allergy to neomycin or to gelatin (components of the vaccine). The steroid dose indicated here is not enough to cause immune-suppression. Review the steroid doses in the text that would be considered a contraindication to live vaccines.
Each of the following groups should receive hepatitis B vaccine except:
A. Unvaccinated adults with ESRD
B. Unvaccinated adults with asthma
C. Sexually-active adults who are not in a long-term, monogamous relationship (1 partner)
D. All infants, beginning at birth
E. Healthcare workers who work in hospitals
A pharmacist is working in a hospital that requires hepatitis B vaccination. She received her 1st dose of a 3-dose series. She did not return for the 2nd dose, which was due one month later. It is now four months after the 1st dose. Select the correct recommendation:
A. She is more than 30 days late with the 2nd dose; she must start the series over.
B. She is more than 60 days late with the 2nd dose; she must start the series over.
C. She is more than 90 days late with the 2nd dose; she must start the series over.
D. She is no longer a candidate for hepatitis B vaccination.
E. She should get the 2nd dose now and return for the 3rd dose at the proper time.
E. Hepatitis B infection is the major infectious hazard for health-care personnel. Persons with chronic infection are at risk for chronic active hepatitis, cirrhosis, and primary liver cancer. There are different vaccines available, but the usual schedule is three doses, given by IM injection: 1st dose followed by a 2nd dose one month later and a 3rd dose six months after the 1st dose. It is acceptable to catch-up on doses if late (give them when the patient comes in), but recommended dosing schedules cannot be sped-up. It is best not to miss vaccines; the delay increases the risk of infection.
Evangelos is a 50 year-old male who approaches the counter to ask for the best option to treat a cut he received on his foot while working in his garden. Evangelos does not believe he received many childhood vaccines. Which vaccine is preferable?
D. A person who gets a cut or burn might need a dose of Td or Tdap to prevent tetanus infection. Tdap should be used for anyone who has never had a dose previously. Td should be used if Tdap is not available, or for anybody who has already had a dose of Tdap, and for adults 65 and older.
The manager at Huntington Pharmacy has ordered 100 single-dose vials of Fluvirin. He found them in the store's freezer. Choose the correct course of action:
A. The vaccine can be moved into the refrigerator if it has been frozen less than 1 hour.
B. The vaccine cannot be used; it must be safely discarded.
C. The vaccine can be used if administered within 24 hours.
D. The vaccine can be used if administered within 48 hours.
E. The vaccine can be used if administered within 72 hours.
B. Vaccine that requires refrigeration cannot be stored in the freezer. If it has been frozen in error, the vaccine has been wasted.
Which of the following groups ages 19-64 years should receive Prevnar followed by Pneumovax at least 8 weeks later and then again 5 years after the first Pneumovax dose? (Select ALL that apply.)
A. A patient with HIV infection.
B. A patient with chronic renal failure.
C. A solid organ transplant recipient.
D. A patient with lymphoma receiving treatment.
E. A patient with multiple myeloma receiving treatment.
A, B, C, D, E. These patients are immunocompromised and should receive this regimen.
Occasionally a patient receives a vaccine that is not administered in the proper location. Which of the following statements concerning intramuscular injection in an adult is incorrect?
A. Inject into the central and thickest portion of the deltoid muscle.
B. The injection site is above the level of the armpit and below the acromium.
C. Separate two injections in the deltoid by a minimum of one inch.
D. Td, Tdap, Hepatitis A, Hepatitis B, HPV, trivalent inactivated influenza, and meningococcal MCV4 are given by IM injection. Polio, IPV, and Pneumovax can be given SC or IM.
E. Always inject into the same arm to ensure consistent absorption.
A pharmacist is preparing an injection for a male patient, 63 years old, who weighs 280 pounds. The pharmacist is going to administer the Zostavax vaccine. Which of the following statements concerning Zostavax injection is correct? (Select ALLthat apply.)
A. Use a needle at least 1.5" long.
B. The vaccine must be reconstituted prior to use with sterile or bacteriostatic water.
C. Zostavax will help protect the patient against a herpes zoster outbreak.
D. The patient is not old enough to receive this vaccine.
E. This vaccine is administered subcutaneously in the fatty tissue over the triceps.
C, E. This injection is given subcutaneously with a needle that is 5/8" long. Pinch up on the tissue to prevent injecting into muscle, although this is more of an issue with thin patients than the patient described in this question. The vaccine must be reconstituted prior to use with the supplied diluent. Zostavax will help protect the patient against a herpes zoster outbreak, which is shingles.
Select the correct statement concerning pneumococcal vaccination in patients 65 and older:
A. They should receive Pneumovax 23 unless received within the past 5 years.
B. They should receive Prevnar 13 unless received within the past 5 years.
C. They should receive Prevnar 13 x 1, followed by Pneumovax 23 five years later.
D. They should receive Prevnar 13 (if not given previously) followed by Pneumovax 23 6 to 12 months later by a dose of Pneumovax 23.
E. They should receive Pneumovax 23 x 1, followed by Prevnar 13 five years later.
D. Ages 65 and older require Prevnar 13 (if not given previously) followed by Pneumovax 23 6 - 12 months later by a dose ofPneumovax 23. If Pneumovax 23 was given first, wait at least 1 year before giving Prevnar 13.
Select the correct name for the chickenpox vaccine:
B. Look-alike drug names contribute to the most common error pharmacists make, which is dispensing the wrong medication.
The shingles vaccine is used to prevent shingles outbreak. Children receive the chickenpox vaccine. Which of the following statements are correct? (Select ALL that apply.)
A. Varivax vaccine is given to persons ages 60 years and older.
B. If a patient has an outbreak and suffers pain, they can use lidocaine orally for pain relief.
C. To prevent varicella (chickenpox) in children they can receive a combination vaccine for MMR and varicella (MMRV) called ProQuad.
D. Another name for shingles is herpes simplex.
E. Varicella vaccines are live vaccines.
C, E. Shingles can cause severe nerve pain. The lidocaine patch (Lidoderm) is approved to treat the pain, and other agents are as well, but the pain can remain significant in 5-10% of patients with shingles. Lidocaine viscous gel is used topically for pain relief. Another name for shingles is herpes zoster. Another name for the resultant chronic pain that may occur post-shingles outbreak is herpetic neuralgia.
Which of the following statements concerning the recombinant vaccine FluBlok are correct? (Select ALL that apply.)
A. If a patient wishes to receive FluBlok and they have had a severe reaction to eggs (anaphylaxis) they cannot receive FluBlok in the pharmacy.
B. FluBlok is produced with recombinant DNA techniques and is completely free of egg products.
C. FluBlok is given subcutaneously.
D. FluBlok is preferred in children E. Flublok can be administered to patients 18 years and older.
B, E. If a patient wishes to receive FluBlok and they have had a severe reaction to eggs (anaphylaxis) they can certainly receiveFluBlok in the pharmacy; FluBlok is a recombinant vaccine and is not produced in hen embryos. FluBlok is 100% egg-free. Children 6 months to 8 years should be receiving FluMist, the quadrivalent nasal spray, per the CDC.
Pharmacists have sometimes dispensed the wrong hepatitis vaccines. It is helpful to know some of the names in order to make sure the correct vaccine is chosen. Vaccines can be kept in labeled bins in the refrigerator with warnings for agents that are likely to be involved in mix-ups. Which vaccine contains combined Hepatitis A and B vaccines?
E. The name Twinrix is a clue ("twin') that two vaccines are included.
Which of the following statements concerning an intramuscular (IM) injection are correct? (Select ALL that apply.)
A. Separate two IM injections by at least one inch.
B. Meningococcal (MCV) is given by IM injection.
C. Varivax is SC only; Zostavax is IM or SC.
D. Inactivated polio vaccine is either SC or IM.
E. Pneumovax is SC only.
A, B, D. Pneumococcal polysaccharide (Pneumovax) and the inactivated polio vaccine (IPV) are either SC or IM; no preference is stated by ACIP.
Epinephrine injection now comes in a "talking" injection device that can help guide patients how to administer the injection. What is the name of this device?
E. Auvi-Q is a newer device that is easy to use; however, the EpiPen is also simple to use.
Evzio (naloxone auto-injector) for opioid overdose
Copaxone (glatiramer acetate) for multiple sclerosis
Lemtrada (alemtuzumab) treats leukemia
Arixtra (fondaparinux) prevents blood clots, factor Xa inhibitor
Benjamin is a 54 year-old male who enters the pharmacy to get his annual flu shot, but he is coughing and sneezing. He has a cold and says his cough kept him up all night. Select the correct statement:
A. He should get the flu shot today.
B. He should wait until the illness symptoms have cleared.
C. He should wait at least a month before he challenges himself with a flu vaccine.
D. He should get FluMist; it is better to avoid a painful shot when you are ill.
E. He should get the intradermal flu shot which causes less swelling than the IM injection.
A. Mild illness is not a contraindication to vaccination.
Many types of medications are self-administered by patients. These require careful instruction by the pharmacists on how to safely store and administer the injection devices or syringes, and how to dispose of the used material. Which of the following statements is correct?
A. The skin where the patient injects is rubbed after an EpiPen injection but is not rubbed after an enoxaparin injetion.
B. The EpiPen is only for use by a trained healthcare professional.
C. The EpiPen can only be self-administered once for each episode.
D. The EpiPen is administered in the abdomen.
E. The EpiPen is kept refrigerated prior to use.
A. Both enoxaparin (Lovenox) and the EpiPen are stored at room temperature. Many self-injectables require refrigeration. It is important to rub the skin after using an EpiPen to help the medication reach the lungs quickly. Do not rub after injecting an anticoagulant; bruising/bleeding could occur in that location.
Which of the following is true regarding herpes zoster vaccine? (Select ALL that apply.)
A. Store the unused vaccine vials (powder) in the refrigerator.
B. Store the unused vaccine vials (powder) at -15 degrees Centigrade.
C. Once reconstituted the vaccine must be used within 30 minutes or discarded, according to ACIP.
D. The diluent must be stored in the refrigerator only.
E. The vaccine is administered SC with a 5/8" needle.
B, C, E.
A 12 month old child was hospitalized two months ago and received immuneglobulin. Which vaccine would be adversely affected by this treatment?
A. Pneumococcal conjugate
B. Polio vaccine
D. Influenza vaccine, shot, inactivated
E. Hepatitis B vaccine
C. Immunoglobulin administration must be separated from live vaccines, including measles and varicella, for at least three months.
A child was not vaccinated for meningococcal disease. The child is at risk for severe disease and complications, including death. Which of the following is true regarding meningococcal disease/vaccine? (Select ALL that apply.)
A. MCV is given IM, MPSV is given SC.
B. Patients who are 2 months-55 years old who are considered high disease risk and should be vaccinated include those living in college dormitories.
C. Patients who are 2 months-55 years old who are considered high disease risk and should be vaccinated include those in the military.
D. Some patients will require repeat vaccination.
E. Meningitis is no longer a routine childhood vaccination.
A, B, C, D. Anyone can get meningitis but it is most common in infants less than one year of age and in people ages 16-21 years. Up to age 55 MCV4 (the conjugate version) is preferred. After age 55 only the polysaccharide version is licensed for use (MPSV4). The redness and pain at the injection site affects about half the patients being vaccinated and dissipates in 1-2 days.
Which of the following, if taken, would qualify as a steroid-induced immune suppressive state? (Select ALL that apply.)
A. The use of a beclomethasone inhaler twice daily for at least 4 weeks.
B. A patient who was recently infected with HIV.
C. An adult who received 4 mg of dexamethasone daily for the past three weeks.
D. An 11.8 kg child receiving 30 mg of prednisolone for the past 22 days.
E. An elderly female who received a triamcinolone intra-articular injection for gout x 1 two days ago.
C, D. Steroid-induced immunesuppression is given in terms of prednisone equivalent doses on page 316 of the Immunization chapter in the 2015 RxPrep course book. The equivalent steroid doses to prednisone are in the asthma chapter of the RxPrep course book.
Inhalers, and injections into the joints do not count as steroid-induced immune suppression.
Which of the following represent patient groups that are candidates for the shingles vaccine, according to the ACIP recommendations?
A. Adults 50 years and older
B. Adults 60 years and older
C. Adults 50 years and older and children at 2-3 months and 10-11 years
D. Adults 60 years and older and children at 2-3 months and 10-11 years
E. Adults 60 years and older and college students who live in dormitories
B. The herpes zoster (shingles) vaccine is live and cannot be given to patients with severe immunosuppression. This includes individuals with AIDS or clinical manifestations of HIV, such as a CD4+ count less than 200 per mm3 and patients on high doses of steroids (prednisone or its equivalent of 20 mg daily or more for more than 2 weeks). It does not matter if the person had chickenpox as a youngster; they can still get shingles and are vaccinated. The FDA has approved the shingles vaccine for adults over 50 years of age, but this is not the current recommendation from ACIP. It may change to match the approval; if this occurs then the protocols used in community pharmacies will need to be amended. There is uncertainty at present over when adults will need a booster--if they get vaccinated at a younger age, then the protection wanes when older. Until this is figured out the ACIP may leave the recommendation at 60.
Select the correct administration site for the influenza injection in an adult (not the intradermal):
B. Gluteus maximus
E. Fatty tissue over the anterolateral thigh muscle or fatty tissue over the triceps
A. Both the influenza and pneumococcal shots are administered by intramuscular (IM) injection to the deltoid muscle, which is located at the upper, outer arm. The syringe is injected straight down at a ninety degree angle. In addition, the pneumococcal vaccine can also be given subcutaneously. Note on Fluzone formulations: Fluzone is approved for use in persons 6 months of age and older. Fluzone High-Dose is approved for use in persons 65 years of age and older.
Hendrick is a community pharmacist who runs a vaccination clinic. He wants to review current vaccine administration recommendations. What source is best for Hendrick to obtain the current vaccine recommendations and other essential immunization information?
A. Centers for Disease Control (CDC) website
B. Koda Kimble: Applied Therapeutics
C. His old pharmacy school notes
D. The vaccine manufacturer's product package inserts
E. A website he found by searching with Google
A. The CDC website contains the vaccination schedules and much useful information. The vaccine updates are generated by the Advisory Committee on Immunization Practices (ACIP) and published in the Morbidity and Mortality Weekly Report (MMWR). All of this information is available from the CDC website. The Pink Book is on the CDC website, in both chapters for free download and some of the topics in slide-sets. The Pink Book (which used to be ordered and was pink--prior to the use of the internet) covers all aspects of immunization, including a background on immunology and principles of immunization.
Select the correct statement concerning the hepatitis B virus:
A. Hepatitis B is a deadly form of the hepatitis virus, yet there is no vaccine available.
B. Hepatitis B is transmitted by ingestion of fecal matter from contaminated foods and drinks.
C. Hepatitis B is transmitted by contact with infected body fluids (sex, IV drug abuse, mother to child, needlestick injury).
D. Pharmacists who work in a hospital and have exposure to needlesticks or blood products are considered low-risk (however, others such as surgeons and nurses require vaccination).
E. Infants are not routinely vaccinated for hepatitis B.
C. Infants are vaccinated for hepatitis B at birth. All healthcare and public safety workers exposed to blood on the job are vaccinated. Persons traveling to regions with high infection rates should consider vaccination. Others receiving vaccination include anyone with multiple sex partners, persons with liver disease and other hepatitis infections, illicit drug users, persons with liver disease or renal disease and anyone who wants protection.
The meningococcal disease can be prevented by the following vaccines: MCV4 and MPSV4. Select the vaccine formulation preferred for ages 2 months - 55 years (if available):
A. Menactra (MCV4)
B. Menveo (MCV4)
C. Menomune (MPSV4)
B. MCV4 is the preferred vaccine for people in these groups who are 2 months through 55 years of age. MPSV4 can be used for adults 56 and older. Menactra is for 9 months-55 years of age.
Menactra: ages 9 months to 55 years, MCV4 give IM
Menveo: ages 2 months to 55 years, MCV4 give IM
Menomune: ages > 56, MPSV4 give SC
Laura, a 29 year-old female, is getting her first job as a hospital pharmacist since completing school. She is excited about the opportunity, but is not excited about getting shots. Laura states that she has a "low pain threshold." She completed her hepatitis vaccine series (3-doses, with evidence of immunity) during pharmacy school. Laura's mother reports that Laura was the only child in the family who did not contract chickenpox. What other vaccines should Laura receive now? (SelectALL that apply.)
A. The influenza vaccine, seasonally.
B. Tdap vaccine, if no record of previous vaccination, and Td every 10 years thereafter.
E. Hib vaccine
A, B, C. Health care workers exposed to meningococcal isolates will need the meningitis vaccine. It is unusual not to have contracted chickenpox, but if this appears to be the case, healthcare workers should receive the vaccine. Children have been receiving the chickenpox vaccine in the U.S. since 1995. Hepatitis B vaccine is required for healthcare workers.
A patient requires the Hepatitis B vaccine and HBIG (hepatitis B immune globulin) due to a recent exposure. Which of the following statements is correct concerning the administration of these two medications?
A. They can be administered on the same day and in the same location but cannot be mixed in the same syringe.
B. They can be administered on the same day, but need to be given in two separate anatomical sites (two different arms).
C. They can be given on the same day and they can be mixed in the same syringe.
D. They cannot be administered on the same day, and must be separated by at least 3 months.
E. They cannot be administered on the same day, and must be separated by at least 6 months.
B. A vaccine and its corresponding immune globulin can be administered on the same day, as long as they are administered at different sites.
Pharmacists have sometimes dispensed the wrong hepatitis vaccines. It is helpful to know some of the names in order to make sure the correct vaccine is chosen. Vaccines can be kept in labeled bins in the refrigerator with warnings for agents that are likely to be involved in mix-ups. Which vaccine is a combined Hepatitis B-Haemophilus influenzae type b (Hib) conjugate vaccine?
Jerry is a 72 year-old male who is due for his tetanus vaccine. Jerry lives in an apartment with his daughter, a 3 month old granddaughter and a 2 year old grandson. He does not know if he ever received the pertussis vaccine. Which vaccine should Jerry receive?
D. Tetanus only
B. Tdap Adacel, Boostrix) is indicated for adults under age 65, but the CDC is recommending it to older adults. They are at risk for pertussis and can pass it along to children and infants who are at highest risk of severe illness. Children get DTaP (5 doses) and older children, adolescents and adults get TdaP.
A patient who had a severe reaction to eggs (with facial swelling or trouble breathing) should not receive the following vaccines in a community pharmacy setting: (Select ALL that apply.)
A. Measles, Mumps and Rubella (MMR)
C. Yellow Fever
C, D, E. A patient who had a severe reaction to eggs (with hives and facial swelling or trouble breathing) should be referred to a physician specializing in allergies prior to receiving the influenza vaccine, except for FluBlok. They may be able to receive the vaccine in this setting, but should not receive it in a community pharmacy. The yellow fever vaccine is not given with a true egg allergy.
A pharmacist is instructing an intern how to administer the EpiPen. Which of the following instructions are important in properly administering the injection?
A. Do not remove the safety cover; removing the cover "caps" the needle and is done after the injection is administered.
B. Inject in the abdomen for best absorption, through clothes if necessary.
C. Hold the injector firmly against the skin over the deltoid for 10 seconds to give the medicine time to disperse.
D. Keep at least one pen in both adult and one in junior sizes in the emergency kit at the pharmacy.
E. Inject into the thigh, hold against skin for at least 10 seconds.
E. Inject in the thigh, through clothes if necessary, after removing the safety cap. If an epinephrine injection is needed, or with any serious reaction, call 911 and follow up with the patient's primary care provider. Any pharmacy administering vaccines must have a protocol that outlines steps to take in the event of an allergic reaction. The protocol steps will be covered in the staff training. Two injections of each size (at the minimum two adult pens) must be in the pharmacy if administering injections. The pen should be held against the thigh with light pressure for at least 10 seconds.
Laura is at the pharmacy today to get her annual flu vaccine. She has just turned 67 years old and never got a pneumococcal vaccine. She has never received the shingles vaccine and it is recommended. Can she get all three vaccines today?
A. Yes, and the two inactivated vaccines (influenza and pneumococcal) can be mixed in the same syringe.
B. No, the shingles is a live vaccine and this must be administered on a different day.
C. She can get all three vaccines today as separate shots.
D. She can get influenza today but needs to wait at least two weeks to receive the other vaccines.
E. She is not a candidate for any of these vaccines due to her age.
C. Simultaneous administration (administration on the same day) is a recommended practice to increase immunization rates. If the patient is present, vaccinate if indicated. Although all the indicated vaccines for the patient can each be given, the individual vaccines cannot be mixed in the same syringe unless they are licensed for mixing by the FDA. If live parenteral (injected) vaccines (MMR, MMRV, varicella, zoster, and yellow fever) and live intranasal influenza vaccine (LAIV) are not administered at the same visit, they should be separated by at least 4 weeks. If more than one injection is given in the same limb, separate the injection sites by at least 1-2 inches. This way, any individual reactions can be observed.
Children ages 6 months who are receiving annual influenza vaccine for the first time require this regimen:
A. A series of three shots at 1 month, 6 months and 12 months.
B. 1 dose to prime the immune system; a 2nd dose 6 months later..
C. 1 dose to prime the immune system; a 2nd dose 28 days later.
D. One shot only of the high-dose Fluzone vaccine.
E. A series of three shots at 1 month, 3 months and 6 months.
Faith is thirteen years old. The mother is upset that the physician suggested that Faith should receive the HPV vaccine. The pharmacist wishes to relay to the mother why this vaccine might be beneficial. Which of the following statements concerning the HPV vaccine are correct? (Select ALL that apply.)
A. HPV is the most common sexually transmitted disease and can cause genital warts and cervical cancer, the 2nd most deadly cancer in women.
B. The vaccine series should be completed before Faith is sexually active.
C. It is true that receiving HPV will encourage her daughter to have sexual relations earlier than she might otherwise, but she should get the vaccine anyway.
D. If she chooses not to have her daughter vaccinated, Faith should be diligent about getting tested with the pap or co-test when she is older (which should be done anyway).
E. HPV vaccine should only be administered to girls; boys are not candidates for the vaccine.
A, B, D. Girls and women can receive either Cervarix and Gardasil from the ages of 11 to 12 years, and for females 13 to 26 years who did not get any or all of the shots when they were younger. These can also be given to girls as young as 9 years of age. It is recommended that females get the same vaccine brand for all three doses, whenever possible. Boys and men ages 9 to 26 years of age can receive Gardasil to protect against most genital warts. Cervarix is not indicated for males; Gardasilhas better coverage for males.
Which vaccines contain hepatitis B vaccine only? (Select ALL that apply.)
A, E. Pediarix contains DTaP-HepB-IPV.
Instruct a nurse on the correct administration technique for FluMist:
A. Leave the protector tip on the vial; do not remove until administering the second half of the dose.
B. Administer the full dose into one nostril.
C. The patient must breathe through their nose forcefully in order to get the dose.
D. Sit upright and bend the head back slightly.
E. Do not administer to children; children must receive the flu shot (until 14 years of age).
D. Remove the blue protector top. Tell your patient to breathe normally. Have the patient sit upright and bend their head back slightly. Place the tip just inside the nostril and depress the plunger as rapidly as possible until the dose divider clip prevents you from pushing further. (If you do not push the plunger rapidly; the full dose will not leave the device.) Pinch and remove the dose divider tip and discard. Administer the 2nd half of the dose to the other nostril. Dispose of the sprayer in a sharps container.
The Centers for Disease Control (CDC) recommend that children ages 2 to 8 years of age receive this type of annual influenza vaccine:
A. Trivalent, intradermal Fluzone
B. Trivalent, nasal FluMist
C. Quadrivalent, intradermal Fluzone
D. Quadrivalent, nasal FluMist
E. Trivalent, high-dose Fluzone
D. The FluMist intranasal vaccine is only available as a quadrivalent formulation and is preferred in this age group.
Which of the following vaccines can be given in the time interval as stated below?
A. MMR and the zoster vaccine (Zostavax) separated by 7 days
B. MMR and the zoster vaccine (Zostavax) separated by 14 days
C. Varivax and FluMist separated by 28 days
D. MMR and FluMist separated by 10 days
E. MMR and FluMist separated by 14 days
C. Live vaccines should be administered on the same day or separated by at least 28 days (4 weeks). There is not a minimum interval for separating an inactivated (the influenza shot) and a live vaccine.
Which of the following statements are correct concerning the vaccination for typhoid? (Select ALL that apply.)
A. Vivotif Berna is capsules, that are kept refrigerated.
B. Typhoid is transmitted by mosquitos; attempt to reduce exposure.
C. Typhoid vaccine comes as oral capsules or as an IM injection.
D. Typhoid vaccine is mostly a concern for travelers to the United States.
E. To reduce typhoid transmission: "Boil it, cook it, peel it, or forget it."
A, C, E. If a vaccine requires refrigeration and it is not stored as such the vaccine will be wasted. Typhoid vaccine is unusual in that it is commonly provided as 4 capsules in a box that require refrigeration. Vaccination needs to be completed at least 1-2 weeks before travel (per the CDC, the package insert says 1 week). Typhoid vaccines lose effectiveness after several years and require boosters. Typhoid fever comes from consuming food or beverages that have been handled by a person who is shedding Salmonella Typhi or from contaminated sewage. It is common in most parts of the world (except in industrialized regions such as the United States, Canada, western Europe, Australia, and Japan). Travelers to the developing world should consider vaccination. To help avoid typhoid disease, the CDC recommends: "Boil it, cook it, peel it, or forget it." Vivotif Berna dosing is unusual too: Take 1 capsule 1 hour before a meal with cold or lukewarm water
A child was not vaccinated for meningococcal disease. The child is at risk for severe disease and complications, including death. Choose the correct statement concerning meningococcal disease:
A. Meningitis is most common in the elderly.
B. Only a very small minority of people who contract meningitis suffer fatality.
C. Menomune can be given to children as young as 2 months.
D. The vaccine is required by the government of Egypt during certain pilgrimages, such as the Hajj.
E. None of the above
E. Meningococcal disease is the leading cause of bacterial meningitis in children 2-18 years old in the United States. About 1000 people get meningococcal disease each year in the U.S. Even when they are treated with antibiotics, 10-15% of these people die. Of those who live, another 11%-19% lose their arms or legs, have problems with their nervous systems, become deaf or mentally retarded, or suffer seizures or strokes. This is why the CDC recommends vaccination for all children, and for high risk groups who did not receive the vaccine when younger (such as college freshman living in dormitories, lab personnel and military recruits). Only Saudi Arabia has requirements for vaccination during the Hajj and Umrah pilgrimages, when many people are in close vicinity and transmission risk is elevated.
Shira will be offering vaccines at her pharmacy in the fall. She is writing a list to order supplies. What type of syringe will she need to administer adult intramuscular injections, such as for the influenza shot and the pneumococcal polysaccharide (Pneumovax) injections? (Select ALL that apply.)
A. Intramuscular injections are given straight down, at a ninety degree angle.
B. Td and Tdap are also both intramuscular injections.
C. Needles that are 22 to 25 gauge are used for IM Injections.
D. Administer at the top border of the deltoid, near the acromion.
E. If women greater than 200 pounds and men greater than 260 pounds a 1 inch needle is required.
A, B, C. Intramuscular (IM) injections are given straight down into the skin (that is a 90 degree angle). This will enable the needle to pass through the subcutaneous layer and enter the muscle mass. The higher the gauge, the thinner the needle. This is the gauge range typically used; check the package insert for the vaccine to confirm the recommended syringe and needle type. SYRINGE SIZE: 1 inch needle is sufficient unless: If women greater than 200 pounds and men greater than 260 pounds a 1 1/2 inch needle is used and the skin should be stretched tight. Administer IM in the central, thickest part of the deltoid.
A small community pharmacy just received a delivery of fall flu vaccine. The pharmacy owner needs to instruct the staff on storage requirements. He should include the following information:
A. The refrigerator temperature is recorded in a log record once daily.
B. The temperature log record is kept for at least one year.
C. The stock should be rotated so that the oldest vaccines (earliest expiration dates) are in the front.
D. The temperature log record can only be maintained by a registered pharmacist or intern.
E. If administering vaccines, the temperature log must be checked every day (including days in which the pharmacy is closed).
C. The temperature in the cold unit must be recorded twice daily and the log should be kept for at least three years. The cold unit temperature must be kept between 2 to 8 degrees Centigrade. Always check the expiration date on the vaccine prior to administration.
Select the correct administration site for the herpes zoster vaccine in an adult:
C. Fatty tissue over the triceps
D. Deltoid muscle
E. Gluteus maximus
C. This is the most likely subcutaneous vaccine (SC) administered in a community pharmacy setting. SC vaccines go into subcutaneous fat and intramuscular vaccines (IM) go into muscle (typically the deltoid muscle in adults). Pneumovax is either SC or IM.
What is an immunization registry?
A. A place where immunization records are kept
B. A place to facilitate record sharing among health care providers
C. A method to help increase immunization rates
D. A method to reduce vaccine-preventable disease
E. All of the above
E. Immunization registries are databases in all fifty states of primarily childhood (and sometimes adult) immunizations. A healthcare provider can access patient records to see which vaccines the patient should receive. The primary purpose of having immunization registries is to increase immunization rates.
Shelly belongs to a religious group that is vegan and consumes no meat or dairy products.. She has come to the pharmacy and asks if any of the vaccines contain animal products. How should the pharmacist respond?
A. There are no animal-derived products whatsoever in any vaccines.
B. Some vaccines contain gelatin, however the dietary regulations for most religions that do not consume animal products religions that do not consume animal products approve of vaccine use since the end product has been rendered pure. A few other vaccines contain egg products and can be avoided.
C. Some vaccines contain gelatin, however the dietary regulations for most religions that do not consume animal products approve of vaccine only when the person's life will be in danger. A few other vaccines contain egg products and can be avoided.
D. The gelatin contained in the MMR and MMR-V vaccines is of measurable amounts and should be avoided in all observant Jews, Muslims and Seventh Day Adventists.
E. Some vaccines contain gelatin, however the dietary regulations for most religions that do not consume animal products approve of vaccine only for diseases that have high rates of communicability among children. A few other vaccines contain egg products and can be avoided.
B. Gelatin is porcine-derived, however the use of this is rendered pure and the product is injected, not ingested. This is fine for most observant groups in these religions, however it may not be fine for individual persons and the pharmacist should be able to discuss this issue with correct information.
Hendrick is a community pharmacist who runs a vaccination clinic. He has run out of the vaccine information sheets (VIS) for one of the vaccines. What are recommended websites to get a current VIS to use to make more copies? (Select ALLthat apply.)
A. From the Pharmacist's Letter
B. From the Medical Letter
C. From the Immunization Action Coalition's Website
D. From the Centers for Disease Control (CDC) website
E. From the World Health Organization (WHO) website
C, D. The CDC website is www.cdc.gov and the Immunization Action Coalition's is www.immunize.org. The VIS handouts change-make sure you are giving a current VIS for each vaccine received. These cover who should get the vaccine and who should not, the complications of the illness and what to expect-including what to do if a serious reaction is experienced. The patient, or their parent, should read it. These two websites also have current vaccine schedules. The Immunization Action Coalition has practical handouts on vaccine storage and administration. The WHO has vaccine information, but in the US we use the VIS prepared by the CDC.
Which of the following vaccines comes as a powder that is stored in the freezer and requires reconstitution with the supplied diluent? (Select ALL that apply.)
A. MMR with Varicella (MMRV, ProQuad)
D. Vivotif Berna
A, B, E. If you did not know that ProQuad was stored and reconstituted the same as the other vaccines, you may be able to make a good guess that it is by considering that the vaccine contains varicella. Also, they are all administered by subcutaneous injection.
Select the correct information for the shingles vaccines as well as the chickenpox vaccine (Zostavax and Varivax):
A. Only Zostavax (not Varivax) can be given during pregnancy.
B. The diluent must be stored in the freezer and the vaccine is refrigerated.
C. Both the diluent and the vaccine are kept frozen until needed.
D. Once drawn up in a syringe, the vaccine must be used quickly; do not store reconstituted vaccine.
E. The vaccines are ready to use; no reconstitution is required.
D. Both vaccines are stored in the freezer. The diluent can be stored at room temperature or in the refrigerator. Once reconstituted, administer by SC Injection right away. Do not store reconstituted vaccine.
A pharmacy that is administering vaccines must be prepared to administer the following medication in the event of an anaphylactic reaction:
A. Epinephrine injection
B. Dexamethasone injection
C. Triamcinolone injection
E. Epinephrine and dexamethasone
A. Epinephrine must be available to treat anaphylaxis. Diphenhydramine can also be given, but epinephrine is the most important first injection to get the airways open so that the patient can breathe. Steroids may be given in the emergency department.
Select the correct statements concerning the hepatitis C virus:
A. Hepatitis C is most commonly spread by accidental needlestick injuries.
B. Hepatitis C is transmitted by ingestion of fecal matter from contaminated foods and drinks.
C. There is no vaccine available to prevent Hepatitis C infection.
D. There are no treatments available for active hepatitis C infection.
E. Few people infected with hepatitis C develop chronic liver disease.
C. This is the most deadly of the hepatitis viruses; about 70% of infected people develop chronic liver disease. There is currently no vaccine for hepatitis C. If positive, the patient may receive treatment with an interferon, alone or in combination with ribavirin. Hepatitis C can be spread by needlestick injuries, sexual contact and can be transmitted from an infected mother to her child, but it is most commonly spread by sharing needles with an infected user (IV drug users).
Coose the corrrect statement concerning immunizations:
A. The CDC does not recommend using acetaminophen before or at vaccination as it may decrease immune response; it can be used afterwards for mild pain and/or fever.
B. You cannot vaccinate through a tattoo; use a different area.
C. According to OSHA, gloves are always required when administering vaccines.
D. If blood is drawn up through the syringe, pull the needle out approximately 1/4 of an inch, and continue injecting.
E. If parents do not wish to vaccinate their children the children will be well protected in the United States by herd immunity.
A small community pharmacy just received a delivery of fall flu vaccine. The pharmacy had a small refrigerator that had a freezer compartment within the refrigerator. He tells the staff to make sure that the FluMist is kept in the refrigerator door to keep it separate from the influenza shot vials. Which of the following vaccine storage information is correct?
A. The refrigerator he purchased is acceptable if the door is not open and closed repeatedly.
B. This type of refrigerator is not acceptable.
C. The vaccine shot vials should be kept in the door.
D. The influenza vaccine should be frozen, not refrigerated.
E. Food can be kept in the same refrigerator but not on the same shelf as the vaccine (or any medication).
B. All vaccines are stored in the center of the refrigerator except for four vaccines that are kept in the freezer (varicella, zoster, MMR, MMRV-this is MMR with varicella). A small refrigerator with an inside freezer shelf does not have reliable temperature control. If food is kept in the refrigerator the unit will have the door open and shut more often--this is not acceptable practice.
A mother asks if her eleven month old son will receive thimerosal from vaccines. She is concerned that this mercury-containing preservative might increase the risk of autism in her son. Select the correct statements. (Select ALL that apply.)
A. Children whose parents do not wish to vaccinate can choose to do so if they live in an urban (not rural) center where the child will likely be protected by "herd" immunity.
B. While it is true that thimerosal is contained in many childhood vaccines, it is not linked to autism.
C. There has been a lack of vaccine-preventable disease occurrence in recent years; instruct the mother to avoid vaccines in her children.
D. Thimerosal may be present in multi-dose influenza vaccines, and can be avoided upon request.
E. The link between vaccines and autism has not been shown to be valid; pharmacists should promote vaccination to reduce disease spread.
D, E. The link between vaccines and autism is not proven and has been well studied. No one needs a lot of mercury, and the thimerosal preservative has been removed from most vaccines. The recent pertussis outbreak indicates that the lack of vaccination among some groups has reduced the protection from herd immunity. FluMist does not contain thimerosal. Some of the multi-dose (but not single dose) influenza shot vials may contain thimerosal-the patient can request an injection without thimerosal and the pharmacy should have this option available.
What does the "a" in DTaP stand for?
A. Acellular, meaning that the pertussis component of the vaccine contains only part of the organism.
B. Atypical, meaning that the vaccine is not the usual type administered.
C. Anachronism, which is a chronological inconsistency.
E. America, where the vaccine was first discovered.
A. The "a" in DTaP and Tdap stands for "acellular", meaning that the pertussis component contains only a part of the pertussis organism. Upper-case letters in these abbreviations denote full-strength doses of diphtheria (D) and tetanus (T) toxoids and pertussis (P) vaccine. Lower-case "d" and "p" denote reduced doses of diphtheria and pertussis used in the adolescent/adult-formulations.
Children get 5 doses of the following tetanus-containing vaccine:
A. Children should get 5 doses of DTaP, one dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years. DT does not contain pertussis, and is used as a substitute for DTaP for children who cannot tolerate pertussis vaccine. Td is a tetanus-diphtheria vaccine given to adolescents and adults as a booster shot every 10 years, or after an exposure to tetanus under some circumstances. Tdap is similar to Td but also contains protection against pertussis and is used commonly in adults with exposure to newborns (to protect the infant from pertussis) and in women during each pregnancy (for the same reason).
Pharmacists have sometimes dispensed the wrong hepatitis vaccines. It is helpful to know some of the names in order to make sure the correct vaccine is chosen. Vaccines can be kept in labeled bins in the refrigerator with warnings for agents that are likely to be involved in mix-ups. Which combination vaccine contains Hepatitis B, Diphtheria, Tetanus, Acellular Pertussis and Inactivated Poliovirus vaccine?
Select the correct statement concerning active and passive immunity:
A. Active immunity is weaker than passive immunity.
B. The MMR vaccine provides active immunity.
C. One way to get passive immunity is to survive an infection.
D. Breast milk, during the early days of a baby's life, provides active immunity.
E. Immune globulin provides active immunity.
B. Active immunity is produced by the person's own immune system and is usually permanent. Ways to acquire active immunity is to survive infection and by receiving vaccination. Passive immunity is protection by products produced by another human (or animal) and transferred to the recipient. The most common form of passive immunity is immunity that an infant receives from its mother at birth or from breast milk. Antibody contained in intravenous immune globulin is a form of passive immunity.
Peter is 45 years old and has a history of asthma, hypertension, anxiety and intermittent depressive episodes. He was drinking a year ago, which resulted in a motor vehicle accident. He received a lung puncture, two fractured ribs and lost his spleen, but has otherwise recovered. He has not had any vaccines since he was an infant. It is October and there are presently no shortages of influenza vaccine. The pharmacist can recommend the following vaccines:
A. Pneumovax and the Fluvarin shot
B. Prevnar and the Fluvarin shot
C. Pneumovax and FluMist
D. Prevnar and FluMist
E. Prevnar, Pneumovax and Fluzone
E. The patient is a candidate for Prevnar, Pneumovax and the flu shot. Fluvarin and Fluzone are both shots (inactivated vaccine).
Shira will be offering vaccines at her pharmacy in the fall. She is writing a list to order supplies. She will be offering theZostavax vaccine. Choose the correct statements concerning Zostavax administration: (Select ALL that apply.)
A. Zostavax vaccine (not the diluent) is stored in the freezer.
B. If giving two vaccines in the same area of fatty tissue separate by at least one inch.
C. MMR is an intramuscular vaccine, and Varivax and Zostavax are not.
D. SC injections are administered at a 45 degree angle.
E. SC injections are administered with a 23 to 25 gauge needle that is 5/8" long.
A, B, D, E. The upper outer arm (the fatty tissue over the triceps) is the preferred site for a SC vaccine injection in an adult. The fatty tissue over the anterolateral thigh muscle can also be used. Other SC injections are preferred in other locations. The needle cannot possibly enter the muscle as it would not reach. With vaccines, a small (45 degree angle) for SC is recommended.
Choose the correct statements concerning the Gardasil or Cervarix vaccinations: (Select ALL that apply.)
A. HPV vaccination is recommended for preteen girls and boys at age 11 or 12 years.
B. Both vaccines can be used for females; Gardasil is used for males.
C. Both vaccines are approved for males.
D. A series of 3 intramuscular injections are required.
E. They should only be given in children who are sexually active.
A, B, D. HPV vaccines are recommended for all teen girls and women through age 26, who did not get all three doses of the vaccine when they were younger. HPV vaccine is recommended for all teen boys and men through age 21, who did not get all three doses of the vaccine when they were younger.
It is very rare for a patient receiving an injection to experience anaphylaxis. However, if any serious reaction does occur to a vaccine, it must be reported to the following agency:
A. The local police department
B. The local department of public health (for your city, or county)
C. The Centers for Disease Control
D. The Morbidity and Mortality Weekly Report
E. Record and report the proceedings of an event to both the patient's physician and to the Vaccine and Adverse Event Reporting System (VAERS), which is run by the FDA and the CDC. The pharmacist may also wish to notify the manufacturer, but must notify VAERS.
How is influenza spread most commonly?
A. Consuming contaminated food and/or water
B. By blood borne products
C. By sexual relations
D. Through respiratory droplets, from sneezing or coughing
E. Influenza is not spread person-to-person; it is contracted from mosquito bites
D. Influenza spreads mainly from person to person through coughing or sneezing of people with influenza. The infection can spread if a person touches something with the virus on it and then touches their mouth or nose. People can infect others beginning on the day before symptoms develop and up to 5 days after becoming sick. Proper hand washing is important to contain the disease spread. Instruct patients to sneeze into their elbow, if a tissue is not handy, rather than into their hands.