A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

Massage the injection site for 15 seconds after administration.

Administer the vaccine into the dorsogluteal muscle.

Ensure the guardian signed an informed consent form for the immunization.

Aspirate for the presence of blood return prior to administering the vaccine.

Answer and Explanation

The Correct Answer is C

A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.

B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.

C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.

D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. While it is a good idea to wear a helmet, the color does not significantly impact safety. The helmet should fit securely and cover the forehead, not the ears.

B. Riding against traffic is unsafe. Cyclists should always ride in the same direction as traffic to ensure they are visible to drivers.

C. The child should always walk the bicycle through crosswalks and intersections to ensure safety and better visibility to drivers.

D. Ensuring the balls of the feet touch the ground while seated on the bicycle helps the child maintain balance and provides a safer, more controlled ride.

A. Tachycardia B. Increased blood pressure C. Increased urinary output D. Bounding peripheral pulses

Correct Answer is A

Explanation

A. Tachycardia is a common finding in infants with heart failure. The body compensates for decreased cardiac output by increasing heart rate to maintain adequate perfusion to vital organs.

B. Blood pressure may not necessarily increase in heart failure. In fact, in severe cases, it can be low due to poor cardiac output.

C. Increased urinary output is not a typical manifestation of heart failure. In fact, heart failure often results in decreased renal perfusion, leading to decreased urine output.

D. Bounding peripheral pulses are usually seen in conditions like fever or hyperdynamic circulatory states, not in heart failure. In heart failure, peripheral pulses may be weak due to reduced cardiac output.

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A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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