A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?
Administer children's aspirin to help prevent inflammation.
Keep the infant home from daycare for the next two days.
Any level of fever is serious and should be reported right away.
Apply a cool pack to the injection site to reduce discomfort.
The Correct Answer is D
Rationale
A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.
B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.
C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.
D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale

A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.
B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.
C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.
D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.
Correct Answer is D
Explanation
Rationale
A. While support groups are important for individuals dealing with chronic illnesses or specific health issues, they are not directly related to primary disease prevention. Support groups focus more on coping, emotional support, and managing existing conditions rather than preventing diseases.
B. Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.
C. Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.
D. Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.
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