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

Administer intramuscularly in the anterolateral thigh.

Divide the medication into two injections if necessary.

Use a 22-25 gauge needle.

Place the child in a comfortable position, preferably sitting upright.

Answer and Explanation

The Correct Answer is A

Choice A reason: The anterolateral thigh is the recommended site for intramuscular injections in toddlers due to the well-developed muscles and minimal risk of injury to nerves or blood vessels.

Choice B reason: Dividing the medication into two injections may be necessary for large volumes, but influenza vaccines typically do not require this.

Choice C reason: A 22-25 gauge needle is recommended for intramuscular injections in toddlers to minimize discomfort and tissue damage.

Choice D reason: While the supine position is not incorrect, a comfortable sitting position is preferable for toddlers to reduce anxiety and ensure a smooth vaccination process.

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Correct Answer is C

Explanation

Choice A reason: Digoxin is used to treat heart conditions by slowing the heart rate and increasing its efficiency. It does not increase the heart rate. The normal heart rate for a 12-month-old infant ranges from 80 to 160 beats per minute.

Choice B reason: If an infant vomits after taking digoxin, repeating the dose could lead to toxicity. Instead, caregivers should wait until the next scheduled dose or contact a healthcare provider for guidance.

Choice C reason: Administering digoxin at regular intervals ensures consistent therapeutic levels in the bloodstream, which is crucial for the medication's efficacy and safety.

Choice D reason: Offering fluids after medication does not interfere with digoxin's absorption. However, caregivers should be aware of the signs of digoxin toxicity, which include vomiting, lethargy, and bradycardia.

A. Oxygen saturation 95% B. Warm extremities C. Wheezing D. Nasal flaring E. Retraction of sternal muscles

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.

Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.

Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.

Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.

Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","E"]

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