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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Passive range-of-motion exercises should be performed to prevent complications like contractures, but they should be done as ordered by the provider, not automatically every 2 hours.
B. Applying protective padding to the end of the pin sites helps prevent pressure injuries and irritation, which is a key part of maintaining skin integrity and preventing infection.
C. There is no indication that fiber intake should be reduced. In fact, a high-fiber diet is encouraged to prevent constipation, which is a common complication for immobile patients.
D. The traction weights should not be lifted off the floor, as this could interfere with the traction setup and the healing process. Traction should be maintained properly to align and stabilize the fracture.
Correct Answer is A
Explanation
A. Encouraging the family to involve siblings in the care of the terminally ill child is important for fostering family support, allowing siblings to understand the situation, and promoting emotional bonding.
B. Avoiding discussions about death is not recommended. It is important to communicate with the child about death in an age-appropriate manner to help them understand and cope with the situation.
C. While monitoring vital signs is important, it is not the most therapeutic intervention in the final stages of terminal illness. Comfort care, including pain management and emotional support, takes priority.
D. Passive range of motion is not essential for a child in the final stages of terminal illness unless necessary for specific comfort or mobility needs. Care should focus on comfort measures rather than routine interventions.
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