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

Answer and Explanation

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).

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Correct Answer is A

Explanation

Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.

Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.

Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.

Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.

A. The reason why the child is taking the medication B. The adverse effects of the medication C. Stopping the medication when the child feels better D. Written information about the medication E. Using a kitchen spoon to administer the medication

Correct Answer is ["A","B","D"]

Explanation

Choice A: The reason why the child is taking the medication

It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.

Choice B: The adverse effects of the medication

Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.

Choice C: Stopping the medication when the child feels better

This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.

Choice D: Written information about the medication

Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.

Choice E: Using a kitchen spoon to administer the medication

This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.

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A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

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Explanation

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