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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Pneumonia is typically transmitted through respiratory droplets, and standard precautions are sufficient for preventing its spread.
Choice B reason:
Correct. Tuberculosis (TB) is an infectious disease that requires contact precautions. This helps prevent the spread of Mycobacterium tuberculosis, the bacteria that cause TB.
Choice C reason:
Haemophilus influenzae type B disease is primarily transmitted through respiratory droplets, so standard precautions are generally sufficient.
Choice D reason:
Respiratory syncytial virus (RSV) is primarily transmitted through respiratory droplets, so standard precautions are generally sufficient. However, in some cases, droplet precautions may be recommended for infants and young children with severe RSV infections.
Correct Answer is A
Explanation
Choice A reason:
Frequent urination is a common symptom of urinary tract infections. It helps to flush out bacteria from the urinary tract.
Choice B reason:
Wiping from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of urinary tract infections. The correct technique is to wipe from front to back
Choice C reason:
Nylon underwear can trap moisture, creating an environment conducive to bacterial growth. Cotton underwear is recommended for better air circulation.
Choice D reason:
Testing urine for ketones is not directly related to preventing urinary tract infections. Ketone testing is more relevant for individuals with diabetes to monitor for ketoacidosis.
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