The nurse suspects a client is hypersensitive to a vaccine just administered. Nursing management of an allergic response includes immediate assessment of the:
A)
dose of medication taken by the client.
B)
skin to check for urticaria.
C)
injection site for signs and symptoms of the inflammatory response.
D)
respirations to determine airway patency.
D
Explanation:
A)
Allergic reactions may include anaphylaxis with laryngeal swelling and difficulty breathing. Airway assessment is the number one priority.
Application
Assessment
Physiological Integrity: Reduction of Risk Potential
B)
Allergic reactions may include anaphylaxis with laryngeal swelling and difficulty breathing. Airway assessment is the number one priority.
Application
Assessment
Physiological Integrity: Reduction of Risk Potential
C)
Allergic reactions may include anaphylaxis with laryngeal swelling and difficulty breathing. Airway assessment is the number one priority.
Application
Assessment
Physiological Integrity: Reduction of Risk Potential
D)
Allergic reactions may include anaphylaxis with laryngeal swelling and difficulty breathing. Airway assessment is the number one priority.
Application
Assessment
Physiological Integrity: Reduction of Risk Potential
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