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 B
Explanation
Choice A reason: Watching a video game in the playroom is not a good activity for a child who requires airborne precautions, as it may expose the child and other children to the risk of infection. Airborne precautions are used for patients who have diseases that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. The child should stay in a private room with negative air pressure, high-efficiency particulate air (HEPA) filtration, and respiratory protection for health care workers and visitors.
Choice B reason: Putting a large-piece puzzle together is a good activity for a child who requires airborne precautions, as it can be done in the child's room and does not involve close contact with others. It is also developmentally appropriate for a 4-year-old child, as it helps to develop fine motor skills, cognitive skills, and problem-solving skills. The nurse should provide the child with a variety of puzzles that are colorful, fun, and challenging, but not frustrating.
Choice C reason: Constructing a model airplane is not a good activity for a child who requires airborne precautions, as it may involve small pieces that can be easily lost, swallowed, or inhaled. It may also be too difficult or complex for a 4-year-old child, who may not have the attention span, dexterity, or patience to complete the task. The nurse should choose activities that are safe, simple, and suitable for the child's age and abilities.
Choice D reason: Pulling a wagon with toys in the hallway is not a good activity for a child who requires airborne precautions, as it may expose the child and other people to the risk of infection. The child should not leave the room unless it is necessary for diagnostic or therapeutic procedures. If the child has to leave the room, the nurse should ensure that the child wears a mask and follows the infection control guidelines. The nurse should also minimize the movement and transport of the child.
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.
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.