A nurse is monitoring a 6-month-old infant 20 min after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?
Temperature 37.7° C (99.9° F)
Redness at the injection site
Prolonged crying
Hives on the child's neck
The Correct Answer is D
Choice A reason:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Children with attention deficit hyperactivity disorder (ADHD) benefit from frequent breaks in activities. Short, focused periods of activity followed by breaks can help them maintain attention and focus.
Choice B reason:
While providing long-term goals is important for building self-esteem, it may not directly address the child's learning style associated with ADHD.
Choice C reason:
Administering medication at bedtime may not be the most effective timing for managing ADHD symptoms. The timing and dosing of ADHD medications should be discussed with the child's healthcare provider.
Choice D reason:
Children with ADHD benefit from consistent routines rather than constantly changing ones. A predictable routine can help them feel more organized and focused.
Correct Answer is A
Explanation
Choice A reason:
When suctioning a tracheostomy tube, it's important to limit the suctioning time to 3 to 4 seconds to avoid hypoxia and trauma to the airway.
Choice B reason:
Sterile technique, not clean technique, is used when performing tracheostomy suctioning to prevent infection.
Choice C reason:
The catheter should be sized appropriately for the tracheostomy tube, but it should not fit too snugly to avoid causing trauma to the airway.
Choice D reason:
Instilling saline prior to suctioning is not recommended as it can lead to complications, including aspiration and increased risk of infection.
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