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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Cold compresses may exacerbate vaso-occlusion in a client with sickle cell anemia and are not recommended.

Choice B reason:

Maintaining bed rest can help reduce the risk of hypoxemia, as it minimizes energy expenditure and oxygen demand.

Choice C reason:

Increasing oral fluid intake is important for preventing vaso-occlusive crises, so decreasing fluid intake is not a recommended intervention.

Choice D reason:

Administering meperidine for fever is not a standard intervention for sickle cell anemia. Fever during a vaso-occlusive crisis should be evaluated and treated according to the underlying cause.

A. Avoid discussing the child's diagnosis with the sibling. B. Designate one parent to stay at home with the sibling. C. Avoid having the sibling visit the child in the facility. D. Encourage phone calls between the siblings.

Correct Answer is D

Explanation

Choice A reason:

Avoiding discussing the child's diagnosis with the sibling may create unnecessary secrecy and could hinder the sibling's understanding and coping.

Choice B reason:

Designating one parent to stay at home with the sibling may not be necessary, as both parents can still provide support and care for both children.

Choice C reason:

Avoiding having the sibling visit the child in the facility may isolate them and prevent opportunities for bonding and support.

Choice D reason:

This statement is correct. Encouraging phone calls between the siblings allows them to maintain communication, express their feelings, and support each other during the separation caused by hospitalization.

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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?

Nursing Test Bank

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