A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture5A_1746709389.jpg" class="img-fluid" /></p>
<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture5AB_1746709427.jpg" class="img-fluid" /></p>
The Correct Answer is A
A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.
B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.
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Related Questions
Correct Answer is A
Explanation
A. Rigid expectations of behavior: Perpetrators of child abuse often have unrealistic and rigid expectations of children’s behavior. When children do not meet these expectations, it can lead to frustration, anger, and abusive responses from the caregiver.
B. Self-blame for financial problems: While financial stress can be a risk factor for family dysfunction, self-blame alone is not a recognized direct characteristic of child abuse perpetrators. Abusive behavior is more often linked to blaming others and lack of coping skills.
C. Laissez-faire leadership style: A laissez-faire leadership style involves being hands-off or permissive, which is not typically associated with abusive behaviors. Abusers are often controlling and overly strict, not permissive.
D. High self-esteem: High self-esteem is generally associated with healthy interpersonal behavior. Low self-esteem, poor coping mechanisms, and unresolved personal trauma are more commonly seen in those who commit child abuse.
Correct Answer is B
Explanation
A. Contact the provider within 48 hr to obtain a prescription for the restraints: A provider’s order for restraints must be obtained immediately or within a very short time frame, usually within 1 hour, depending on facility policy. Waiting 48 hours would be inappropriate and could lead to violation of patient rights.
B. Remove the restraints from the client's wrists every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, provide range of motion exercises, and evaluate the continued need for restraints. This practice ensures client safety, prevents complications such as pressure injuries, and respects client dignity.
C. Check that one finger will fit between the client's wrists and the restraints: The correct practice is to ensure that two fingers can fit between the restraint and the skin to prevent circulatory impairment and skin breakdown. One finger would be too tight and could increase the risk of injury.
D. Fasten the restraints' ties to the bed's side rails: Restraints should always be tied to the bed frame, not the side rails. Attaching restraints to movable parts like side rails can cause injury if the rail is lowered or repositioned, leading to unnecessary strain or trauma to the client.
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