The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?
Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular injection.
Divide the medication into two injections with volumes under 1 mL.
Administer into the deltoid muscle while the parent holds the infant securely.
Use a quick dart-like motion to inject into the dorsogluteal site.
The Correct Answer is B
Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.
In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.
Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).
The client has gestational diabetes mellitus (GDM), which is a condition that affects some pregnant women and causes high blood sugar levels. This is bad during pregnancy because it can increase the risk of complications for both the mother and the baby, such as preeclampsia, macrosomia, birth trauma, neonatal hypoglycemia, and congenital anomalies. The client needs to follow a diet and exercise plan to control her blood sugar levels and prevent further complications. She may also need to take insulin injections or oral medications if diet and exercise are not enough. The client should monitor her blood sugar levels regularly and report any abnormal results to her health care provider. The client should also have regular prenatal visits and ultrasounds to check the growth and development of the baby.
Correct Answer is ["A","C","E"]
Explanation
The correct answer/s is Choice/s A, C, and E.
Choice A rationale: Obtaining the client’s tympanic temperature measurement is a crucial step. The client’s confusion and disorientation could be symptoms of an infection, such as a urinary tract infection or pneumonia. Infections in older adults can often present with atypical symptoms, including changes in mental status. Therefore, checking the client’s temperature can help identify if the client has a fever, which is a common sign of an infection.
Choice B rationale: While it’s always important to be aware of a client’s allergies, especially when administering medications, it doesn’t directly address the immediate concern of the client’s altered mental status. Therefore, it’s not the most appropriate action to take in response to the situation described.
Choice C rationale: Asking if the client is experiencing any pain with urination is relevant because urinary tract infections (UTIs) are common in older adults and can cause confusion and other changes in mental status. Pain during urination is a common symptom of a UTI.
Choice D rationale: Encouraging the intake of high protein foods is generally a good recommendation for older adults to maintain their strength and energy levels. However, it’s not directly related to the client’s current symptoms of confusion and disorientation.
Choice E rationale: Determining if the client has recently experienced a fall is important. Falls in older adults can lead to injuries, such as a head injury, which can cause confusion and other changes in mental status. Additionally, some medications used to treat pain after a fall can also contribute to confusion.
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