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 C

Explanation

Choice A reason: Escorting the parents out of the room may increase their anxiety and distress, as they may want to be close to their child during such a critical time.

Choice B reason: Allowing one parent to sit on the bed may interfere with the medical team's efforts and is not typically recommended during active resuscitation.

Choice C reason: Allowing the parents to stay in the room can provide them with some comfort, knowing they are near their child, and may help in the grieving process if the outcome is unfavorable, as long as they do not interfere with the medical procedures.

Choice D reason: Bringing additional family members into the room during resuscitation can create a chaotic environment and may hinder the medical team's ability to work efficiently. It is better to have a controlled number of people in the room.

A. Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely. B. Document the glucose reading in the electronic medical record as the only action needed. C. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis. D. Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is most appropriate for a school-age child with congenital heart block who codes in the emergency department (ED), while the parents witness the resuscitation scene?

Correct Answer is C

Explanation

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Correct Answer is A

Explanation

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