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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Enlarged painless, firm cervical lymph nodes are a classic sign of Hodgkin’s disease.
Choice B reason: A protuberant, firm abdomen is not a specific finding associated with Hodgkin’s disease.
Choice C reason: A soft to hard, nontender mass in the pelvic area could indicate various conditions but is not specific to Hodgkin’s disease.
Choice D reason: Painful lymph nodes are more commonly associated with infections, not Hodgkin’s disease.
Correct Answer is C
Explanation
Choice A reason: While vitamin C in juices can enhance iron absorption, they are not sufficient sources of iron by themselves.
Choice B reason: Cow's milk can interfere with iron absorption and is not recommended in high quantities for a child with anemia.
Choice C reason: This is the correct choice. These foods are rich in iron, which is essential for treating anemia.
Choice D reason: These are healthy options but do not provide the necessary iron content to effectively address anemia.
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