A nurse is assessing a client who received the measles, mumps, and rubella virus vaccine. Which of the following findings indicates an adverse reaction to the vaccination?
Bradycardia
Petechiae
Tinnitus
Blurred vision
The Correct Answer is B
MMR vaccine can cause bleeding under the skin presenting as petechiae. Petechiae are small red or purple spots caused by bleeding into the skin.
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A,C,D- MMR vaccine is not associated with bradycardia, tinnitus or blurred vision
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypoglycemia is a potential complication of parenteral nutrition, especially if the infusion rate is too high or if the infusion is interrupted. The nurse should promptly address hypoglycemia by administering IV dextrose, which will help raise the client's blood glucose levels.
A. Discontinuing the infusion may be necessary if the cause of hypoglycemia is related to the parenteral nutrition solution or if the infusion rate needs adjustment. However, the immediate priority is to treat the hypoglycemia by providing a glucose source.
C. Warming the formula to room temperature is not relevant to treating hypoglycemia. Warming the formula might be done for other reasons, such as improving tolerance or reducing discomfort during administration.
D. Obtaining arterial blood gases is not indicated for treating hypoglycemia. Arterial blood gases are typically obtained to assess oxygenation and acid-base balance, not glucose levels.
Correct Answer is D
Explanation
The injection should be done on the anterolateral or posterolateral abdominal wall. This is because there is adequate distribution of subcutaneous tissue in this region preventing injection into the muscle.
C-The skin should be pinched to ensure that the injection is delivered into the subcutaneous tissue
A-Massaging the area may cause irritation
B-The bubble should not be expelled
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