A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take?

Administer intramuscularly in the anterolateral thigh.

Divide the medication into two injections if necessary.

Use a 22-25 gauge needle.

Place the child in a comfortable position, preferably sitting upright.

Answer and Explanation

The Correct Answer is A

Choice A reason: The anterolateral thigh is the recommended site for intramuscular injections in toddlers due to the well-developed muscles and minimal risk of injury to nerves or blood vessels.

Choice B reason: Dividing the medication into two injections may be necessary for large volumes, but influenza vaccines typically do not require this.

Choice C reason: A 22-25 gauge needle is recommended for intramuscular injections in toddlers to minimize discomfort and tissue damage.

Choice D reason: While the supine position is not incorrect, a comfortable sitting position is preferable for toddlers to reduce anxiety and ensure a smooth vaccination process.

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Correct Answer is B

Explanation

Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.

Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.

Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.

Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.

A. Hypoventilation B. Tachypnea C. Nonproductive cough D. Nasal stuffiness

Correct Answer is B

Explanation

Choice A reason: Hypoventilation is a late sign of hypoxemia and is characterized by an abnormally slow breathing rate, reducing oxygen intake and increasing carbon dioxide in the blood.

Choice B reason: Tachypnea, or rapid breathing, is an early sign of hypoxemia as the body attempts to increase oxygen levels by breathing more quickly.

Choice C reason: A nonproductive cough is not directly related to hypoxemia, which is a deficiency in the amount of oxygen reaching the tissues.

Choice D reason: Nasal stuffiness is not a specific indicator of hypoxemia and can be associated with various conditions.

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A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take?

Nursing Test Bank

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