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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A Hemoglobin A1C level of 6.2% is within the target range for most adults with diabetes and indicates good blood sugar control over the past 2 to 3 months.
Choice B reason: A fasting plasma glucose of 189 mg/dL is above the target range for fasting blood sugar levels, indicating that the client may not be adhering to the diabetic regimen.
Choice C reason: While an HDL of 40 mg/dL is at the lower limit of the normal range, it does not provide direct information about blood sugar control.
Choice D reason: A postprandial plasma glucose of 225 mg/dL is above the target range for after-meal blood sugar levels, suggesting that the client's diabetes is not well-controlled.

A. Limit water intake to prevent hyponatremia. B. Check blood glucose every 8-12 hours. C. Drink 8oz of apple or orange juice every hour. D. Always give scheduled insulin even if the child has no appetite.

Correct Answer is D

Explanation

Choice A reason: Limiting water intake is not recommended as adequate hydration is important, especially when sick.
Choice B reason: Checking blood glucose every 8-12 hours is not frequent enough; it should be monitored more often during illness.
Choice C reason: Drinking juice every hour is not necessary and could lead to hyperglycemia if not balanced with insulin.
Choice D reason: This is the correct choice. It is crucial to continue administering insulin as prescribed to manage blood glucose levels, even if the child is not eating as much.

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What is the priority nursing assessment for the nurse to perform after administering vaccines?

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