A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Temperature 37.7° C (99.9° F)

Redness at the injection site

Prolonged crying

Hives on the child's neck

Answer and Explanation

The Correct Answer is D

Choice A reason:

A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.

Choice B reason:

Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.

Choice C reason:

Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.

Choice D reason:

Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.

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Correct Answer is D

Explanation

Choice A reason:

Bryant traction is used in infants with congenital hip dysplasia. It is not a form of skin traction for lower extremity fractures in adolescents.

Choice B reason:

Cervical skin traction is used for cervical spine injuries or surgeries, not for lower extremity fractures.

Choice C reason:

Dunlop traction is used for fractures of the humerus.

Choice D reason:

Buck extension traction is applied to the lower leg and uses a boot on the affected leg with weights to provide traction. It is commonly used for lower extremity fractures in adolescents.

A. Reduce intake of foods containing fiber while nonambulatory. B. Gently lift the traction weights off the floor when repositioning the client. C. Perform passive range-of-motion exercises to the affected extremity every 2 hr. D. Apply protective padding to the end of the pin sites.

Correct Answer is C

Explanation

Choice A reason:

Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.

Choice B reason:

The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.

Choice C reason:

Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.

Choice D reason:

Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.

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A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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