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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A urinary tract infection is a common cause of urinary incontinence in children and should be evaluated first.
Choice B reason: While emotional trauma can cause changes in behavior, including incontinence, it is not the first complication to be evaluated in this scenario.
Choice C reason: Sexual abuse can result in behavioral changes, but there is no immediate indication of this being the cause without further assessment.
Choice D reason: A structural defect of the urinary tract could cause incontinence, but it is less likely to be the cause of a sudden onset of symptoms compared to a urinary tract infection.

A. Measure the child's temperature and postpone the immunizations if the fever is over 100°F. B. Administer the vaccinations as scheduled. C. Give the infant the flu vaccination but withhold the others. D. Postpone all vaccinations.

Correct Answer is A

Explanation

Choice A reason: It is crucial to assess for fever, as a fever over 100°F after exposure to the flu may indicate an active infection, necessitating the postponement of immunizations.

Choice B reason: Administering vaccinations without assessing the child's health status, especially after known exposure to the flu, could be risky.

Choice C reason: Giving only the flu vaccination ignores the potential risk of the infant currently incubating the flu virus, which could be exacerbated by vaccination.

Choice D reason: While withholding all vaccinations is a cautious approach, it is not necessary unless the infant shows signs of illness, such as a fever over 100°F.

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What is the priority nursing assessment for the nurse to perform after administering vaccines?

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