A nurse is assessing a client who received the measles, mumps, and rubella virus vaccine. Which of the following findings indicates an adverse reaction to the vaccination?
Bradycardia
Petechiae
Tinnitus
Blurred vision
The Correct Answer is B
MMR vaccine can cause bleeding under the skin presenting as petechiae. Petechiae are small red or purple spots caused by bleeding into the skin.
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A,C,D- MMR vaccine is not associated with bradycardia, tinnitus or blurred vision
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The air bubble should not be expelled from the syringe or aspirate. The air bubble in the syringe of enoxaparin is intended to remain to ensure the full dose of medication is administered.
B-Avoid rubbing a sit may increase the risk of bleeding /irritation
C-The injection is made into the anterolateral or posterolateral aspect of the thigh
D-The skin should not be released before injection as the medication may be injected into the muscle
Correct Answer is A
Explanation
PT measures the time it takes for blood to clot, and it is particularly relevant for clients taking warfarin because warfarin works by inhibiting the synthesis of certain clotting factors, including factors II, VII, IX, and X, which are involved in the PT pathway. Monitoring PT levels helps ensure that the client is receiving an appropriate dose of warfarin to prevent clot formation without causing excessive bleeding.
B. Total iron-binding capacity (TIBC) is a test used to assess iron levels in the blood and is unrelated to warfarin therapy.
C. WBC (White Blood Cell count) is a test used to assess the number of white blood cells in the blood and is unrelated to warfarin therapy.
D. PTT (Partial Thromboplastin Time) is a test used to evaluate the intrinsic and common pathways of the coagulation cascade. It is used in the monitoring of heparin anticoagulant therapy. It is not typically used to monitor warfarin therapy
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