What is the priority nursing assessment for the nurse to perform after administering vaccines?
Symptoms of infection
Anaphylaxis
Pain at the injection site
Myalgia
Hyperthermia
The Correct Answer is B
Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.
Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.
Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.
Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.
Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Non-opioid analgesics are typically not strong enough to manage the severe pain associated with a sickle cell crisis.
Choice B reason: Guided imagery can be a helpful adjunct, but it is not the primary method of pain control during a crisis.
Choice C reason: Diversional activities may help distract from the pain but are not sufficient as the sole method of pain management.
Choice D reason: This is the correct choice. An IV PCA (patient-controlled analgesia) allows the child to manage pain effectively and is appropriate for severe pain during a sickle cell crisis.
Correct Answer is C
Explanation
Choice A reason: Feeding the toddler is important, but it does not specifically address the development of autonomy or decision-making skills.
Choice B reason: Dressing the toddler is a necessary task, but it does not encourage the child's active participation or independence.
Choice C reason: Offering the toddler a choice of clothing allows the child to make decisions, fostering a sense of control and independence, which is developmentally appropriate and empowering for the toddler.
Choice D reason: Asking the toddler if he would like to take his medicine is a good practice to involve the child in their care, but it is not as impactful on development as offering choices that promote autonomy.
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