What is the priority nursing assessment for the nurse to perform after administering vaccines?
Symptoms of infection
Anaphylaxis
Pain at the injection site
Myalgia
Hyperthermia
The Correct Answer is B
Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.
Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.
Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.
Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.
Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.
Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.
Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.
Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Rheumatic fever is often preceded by an upper respiratory infection caused by group A Streptococcus, which can lead to a sore throat.
Choice B reason: Chest trauma and a fractured rib are not related to the development of rheumatic fever.
Choice C reason: Although a pre-existing heart defect can increase the risk of complications, it is not the cause of rheumatic fever.
Choice D reason: A decreasing appetite over several months is not specifically indicative of rheumatic fever.
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