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 C
Explanation
Choice A reason: Continuing to monitor the client is not the best action, as it does not address the low urine output of the child. The child has a urine output of 20 mL/hr, which is below the expected range of 30 to 40 mL/hr for a 3-year-old child. Low urine output can indicate dehydration, kidney injury, or urinary tract obstruction, which require prompt intervention.
Choice B reason: Performing a bladder scan at the bedside is not the most appropriate action, as it is not the first-line diagnostic tool for low urine output. A bladder scan is a noninvasive ultrasound device that measures the amount of urine in the bladder. It can help detect urinary retention, which is the inability to empty the bladder completely. However, urinary retention is unlikely in a 3-year-old child, and a bladder scan may not be accurate or reliable in children.
Choice C reason: Providing oral rehydration fluids is the best action, as it can help restore the fluid and electrolyte balance of the child. Oral rehydration fluids are solutions that contain water, sugar, and salt in specific proportions that match the body's needs. They can prevent or treat dehydration, which is a common cause of low urine output in children. The nurse should offer the child oral rehydration fluids every 15 to 20 minutes, and monitor the urine output, vital signs, and hydration status.
Choice D reason: Notifying the provider is not the first action, as it is not the most urgent or effective intervention for low urine output. The nurse should notify the provider after providing oral rehydration fluids and assessing the child's response. The nurse should also report any signs or symptoms of dehydration, such as dry mucous membranes, sunken eyes, poor skin turgor, or lethargy. The provider may order further tests or treatments, such as blood tests, urine tests, or intravenous fluids.
Correct Answer is B
Explanation
Choice A reason: The onset of low blood glucose, or hypoglycemia, usually occurs rapidly and can be triggered by skipping meals, exercising too much, or taking too much insulin. The nurse should teach the parents to recognize the signs and symptoms of hypoglycemia and how to treat it promptly.
Choice B reason: Feeling shaky is one of the common signs of low blood glucose, along with hunger, sweating, dizziness, confusion, and irritability. The nurse should teach the parents to check the child's blood glucose level and give him a fast-acting carbohydrate, such as juice, candy, or glucose tablets, if it is below 70 mg/dL.
Choice C reason: Sweating can occur with low blood glucose, not high blood glucose, or hyperglycemia. Hyperglycemia can cause symptoms such as thirst, frequent urination, dry mouth, blurred vision, and fatigue. The nurse should teach the parents to monitor the child's blood glucose level regularly and adjust his insulin dose, diet, and exercise accordingly.
Choice D reason: Nausea and vomiting can occur with high blood glucose, especially if it leads to diabetic ketoacidosis, a serious complication of diabetes. Diabetic ketoacidosis can also cause abdominal pain, fruity breath, rapid breathing, and coma. The nurse should teach the parents to seek emergency medical attention if the child has these symptoms.
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