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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A low serum creatinine level indicates decreased muscle mass or impaired kidney function. However, it does not necessarily indicate that the 24-hour creatinine clearance test should be withheld or delayed.

Initiating the urine collection as prescribed allows for the accurate assessment of creatinine clearance and provides valuable information about the client's kidney function. The test results can help guide further evaluation and management of the client's condition.

Assessing the client's serum BUN level, notifying the healthcare provider of the results, or assessing for signs of hypokalemia may be relevant in certain situations but are not the immediate priority based on the information provided.

A. Use firmness and direct the client to sit for awhile. B. Suggest to the client that he take a walk. C. Move the client to a quiet place on the unit. D. Encourage the client to use the punching bag

Correct Answer is C

Explanation

Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.

Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.

Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.

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The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

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Correct Answer is A

Explanation

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Correct Answer is C

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