The nurse suspects that a client is hypersensitive to a vaccine just administered. Nursing management of an allergic response includes immediate assessment of the:
1. injection site for signs and symptoms of the inflammatory response.
2. skin to check for urticaria.
3. dose of medication taken by the client.
4. respirations to determine airway patency.
Answer: 4
1. Skin changes might not occur as part of the inflammatory response.
2. Urticaria might not occur with an allergic response.
3. The medication dose should have been checked before injecting.
4. Allergic reactions can include anaphylaxis with laryngeal swelling and difficulty breathing. Airway assessment is the number one priority.
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