A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?
Use a 20 gauge needle
Insert the needle just below the acromion process
Insert the needle at a 15 degree angle
Use a 1.8 mm (0.5 in) needle
The Correct Answer is D
Choice A reason: Using a 20 gauge needle is not the best action, as it is too large for a preschooler's deltoid muscle. A 20 gauge needle has a diameter of 0.9 mm, which may cause more pain and tissue damage. A smaller gauge needle, such as a 23 or 25 gauge, is recommended for intramuscular injections in children.
Choice B reason: Inserting the needle just below the acromion process is not the best action, as it may not reach the deltoid muscle. The acromion process is the bony prominence at the top of the shoulder. The deltoid muscle is located on the lateral aspect of the upper arm, about two finger widths below the acromion process. The nurse should palpate the acromion process and measure the distance to the injection site.
Choice C reason: Inserting the needle at a 15 degree angle is not the best action, as it may not penetrate the muscle tissue. A 15 degree angle is used for intradermal injections, which are given into the dermis, the layer of skin below the epidermis. Intramuscular injections are given into the muscle tissue, which requires a 90 degree angle. The nurse should hold the syringe perpendicular to the skin and insert the needle quickly and firmly.
Choice D reason: Using a 1.8 mm (0.5 in) needle is the best action, as it is the appropriate length for a preschooler's deltoid muscle. The length of the needle should be based on the child's age, weight, and muscle mass. A 1.8 mm (0.5 in) needle is suitable for children who weigh less than 12 kg (26 lb). A longer needle, such as a 2.5 mm (1 in) needle, may be used for children who weigh more than 12 kg (26 lb).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Encouraging the child to avoid sharing hats with other children is a preventive measure to reduce the risk of lice transmission. Lice are spread by direct contact with the hair or personal items of an infested person. Hats, combs, brushes, scarves, and pillows are some of the items that can harbor lice.
Choice B reason: The lice can survive for 2 weeks away from the host is a false statement. Lice cannot live longer than 24 to 48 hours without a human host. They need blood to survive and reproduce. Therefore, this information is not helpful for the parents to prevent or treat lice.
Choice C reason: Washing your child's hair daily will prevent lice is a false statement. Lice are not a sign of poor hygiene or cleanliness. They can affect anyone regardless of how often they wash their hair. In fact, lice may prefer clean hair because it is easier to attach to. Therefore, this information is not helpful for the parents to prevent or treat lice.
Choice D reason: Lice can jump from one child to another is a false statement. Lice cannot jump, fly, or hop. They can only crawl from one person to another. Therefore, this information is not helpful for the parents to prevent or treat lice.
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the length of the straps of the Pavlik harness by themselves, as this may affect the position and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not breastfeed the infant while wearing the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to remove the harness before breastfeeding the infant, and to reapply it after feeding.
Choice C reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should place the diaper under the straps of the harness, as this prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.
Choice D reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.