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A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae Type b (Hib) conjugate vaccine.
Which instruction should the nurse provide?

A.

Any level of fever is serious and should be reported right away.

B.

Keep the child home from daycare for the next two days.

C.

Apply a cool pack to the injection site to reduce discomfort.

D.

Chewable children’s aspirin will help prevent inflammation.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While it’s important to monitor for any adverse reactions following a vaccination, not all fevers are serious. Mild fever can be a common side effect of vaccinations and is usually not a cause for concern. However, if the child develops a high fever, or if the fever is accompanied by other severe symptoms such as difficulty breathing or extreme lethargy, it should be reported to a healthcare provider immediately.

Choice B rationale:

There is no need to keep the child home from daycare following the Hib vaccine unless the child is feeling unwell or has other symptoms that warrant staying home. The Hib vaccine is not a live vaccine, so the child cannot transmit the vaccine strain to others.

Choice C rationale:

Applying a cool pack to the injection site can help reduce discomfort or swelling that may occur after the vaccination. This is a safe and effective method for managing minor side effects of vaccinations.

Choice D rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used to help manage any pain or fever following the vaccination, if approved by a healthcare provider. Always follow the dosing instructions on the package and consult with a healthcare provider if unsure.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

Correct Answer is C

Explanation

Choice A rationale:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

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