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
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Keeping suction equipment at bedside is important to maintain airway patency and prevent aspiration.
Choice B reason: Positioning the child upright for feedings can help prevent aspiration and is a recommended practice.
Choice C reason: Feeding slowly using specialized feeding bottles can help the infant feed effectively and safely.
Choice D reason: This is the correct choice. Breastfeeding is often possible with the use of special techniques and should not be discouraged unless specifically contraindicated.
Correct Answer is D
Explanation
Choice A reason: Pulselessness is not a sign of normal AV fistula function; a palpable pulse should be present.
Choice B reason: An ecchymotic area suggests bruising and is not indicative of normal function.
Choice C reason: Redness may indicate inflammation or infection, not normal function.
Choice D reason: This is the correct choice. An enlarged vein is typical for an AV fistula and indicates good blood flow through the fistula.
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