A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

Use a 20 gauge needle

Insert the needle just below the acromion process

Insert the needle at a 15 degree angle

Use a 1.8 mm (0.5 in) needle

Answer and Explanation

The Correct Answer is D

Choice A reason: Using a 20 gauge needle is not the best action, as it is too large for a preschooler's deltoid muscle. A 20 gauge needle has a diameter of 0.9 mm, which may cause more pain and tissue damage. A smaller gauge needle, such as a 23 or 25 gauge, is recommended for intramuscular injections in children.

Choice B reason: Inserting the needle just below the acromion process is not the best action, as it may not reach the deltoid muscle. The acromion process is the bony prominence at the top of the shoulder. The deltoid muscle is located on the lateral aspect of the upper arm, about two finger widths below the acromion process. The nurse should palpate the acromion process and measure the distance to the injection site.

Choice C reason: Inserting the needle at a 15 degree angle is not the best action, as it may not penetrate the muscle tissue. A 15 degree angle is used for intradermal injections, which are given into the dermis, the layer of skin below the epidermis. Intramuscular injections are given into the muscle tissue, which requires a 90 degree angle. The nurse should hold the syringe perpendicular to the skin and insert the needle quickly and firmly.

Choice D reason: Using a 1.8 mm (0.5 in) needle is the best action, as it is the appropriate length for a preschooler's deltoid muscle. The length of the needle should be based on the child's age, weight, and muscle mass. A 1.8 mm (0.5 in) needle is suitable for children who weigh less than 12 kg (26 lb). A longer needle, such as a 2.5 mm (1 in) needle, may be used for children who weigh more than 12 kg (26 lb).

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Correct Answer is B

Explanation

Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.

Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.

Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.

Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.

A. Insulin therapy and fluid replacement B. Glucagon injection and potassium supplements C. Bicarbonate infusion and sodium restriction D. Dextrose infusion and diuretics

Correct Answer is A

Explanation

Choice A reason: Insulin therapy and fluid replacement are the main treatments for DKA, as they lower the blood glucose level and correct the dehydration and electrolyte imbalance caused by osmotic diuresis and acidosis.

Choice B reason: Glucagon injection and potassium supplements are not indicated for DKA, as they may worsen the hyperglycemia and the hyperkalemia. Glucagon stimulates the liver to release more glucose into the bloodstream, while potassium supplements may increase the risk of cardiac arrhythmias.

Choice C reason: Bicarbonate infusion and sodium restriction are not the first-line treatments for DKA, as they may have adverse effects on the acid-base balance and the fluid status. Bicarbonate infusion may cause paradoxical cerebral acidosis and hypokalemia, while sodium restriction may exacerbate the hyponatremia and the hypovolemia.

Choice D reason: Dextrose infusion and diuretics are contraindicated for DKA, as they may increase the blood glucose level and the dehydration. Dextrose infusion may trigger a rebound hyperglycemia, while diuretics may cause further fluid and electrolyte loss.

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A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

Nursing Test Bank

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