A nurse is preparing to administer an IM injection to a preschool-age child.
Which of the following actions should the nurse take?
Tell the child the medicine will make him feel better.
Ask the parents to hold the child.
Allow the child to hold a favorite toy.
Administer the medication in the child’s room.
The Correct Answer is C
Choice A rationale
While it’s important to explain to a child why they are receiving medication, simply telling them that it will make them feel better may not be enough to alleviate their fear or anxiety about receiving an injection.
Choice B rationale
Asking the parents to hold the child during an injection can be traumatic for both the child and the parent. It’s generally recommended to have a trained healthcare professional hold the child in a safe and secure manner.
Choice C rationale
Allowing the child to hold a favorite toy can provide comfort and distraction during the injection.
Choice D rationale
While it might seem like a good idea to administer the medication in the child’s room where they feel safe, this can actually make the child associate their safe space with negative experiences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Asking the guardians to leave during the procedure is not recommended. The presence of a familiar person can provide comfort and reduce anxiety for the toddler during a stressful procedure.
Choice B rationale
Performing the procedure with the child in his bed can provide a sense of security and familiarity, which can help reduce anxiety and fear.
Choice C rationale
Using the child’s favorite toy to explain or distract during the procedure can help the child understand what to expect and provide a sense of control.
Choice D rationale
Applying lidocaine and prilocaine (EMLA) Cream to 2-3 potential insertion sites can help numb the area and reduce pain during the procedure.
Choice E rationale
Allowing the child to make one choice regarding the procedure can provide a sense of control and cooperation.
Correct Answer is A
Explanation
Choice A rationale
Edema in the palm of the hand is a sign of IV infiltration. IV infiltration occurs when IV fluids or medications leak into the surrounding tissues outside the intended vein. This can cause swelling or edema, which is a common sign of infiltration.
Choice B rationale
Absence of blanching at the insertion site is not necessarily an indication of an infiltration. Blanching (whitening of the skin) can occur due to various reasons, including pressure on the site or a reaction to the IV fluid or medication. However, it is not a definitive sign of infiltration.
Choice C rationale
Warmth around the insertion site is not a definitive sign of an infiltration. While warmth can occur due to inflammation or infection, it is not a specific sign of infiltration.
Choice D rationale
Blood in the IV tubing is not a definitive sign of an infiltration. While blood can back up into the IV tubing due to various reasons, including a blocked or kinked catheter, it is not a specific sign of infiltration.
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