A nurse in an acute care facility is collecting data from a client who has received the meningococcal conjugate vaccine.
The nurse should monitor the client for which of the following findings as an adverse effect of the vaccine?

Choice A rationale:

Pinching the tube while connecting the syringe to it could potentially damage the tube and does not aid in medication administration.

Choice B rationale:

Elevating the head of the client’s bed to only 10° may increase the risk of aspiration. The head of the bed should be elevated to at least 30° during medication administration and for at least an hour afterward.

Choice C rationale:

Flushing the tube with normal saline following medication administration helps ensure that all medication has been administered and helps maintain tube patency.

Choice D rationale:

Combining crushed medications together in a single syringe can lead to drug interactions and can also increase the risk of tube clogging. Each medication should be administered separately.

Choice A rationale:

A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.

Choice B rationale:

Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.

Choice C rationale:

A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.

Choice D rationale:

A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.