A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?
Massage the injection site for 15 seconds after administration.
Administer the vaccine into the dorsogluteal muscle.
Ensure the guardian signed an informed consent form for the immunization.
Aspirate for the presence of blood return prior to administering the vaccine.
The Correct Answer is C
A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.
B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.
C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.
D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Crushing sustained-release tablets is not recommended because it can alter the medication's intended effect, releasing it all at once, which can be dangerous for the child.
B. Allowing medications to flow into the tube by gravity is the correct method. It ensures the medication is delivered slowly and effectively, preventing the tube from clogging and ensuring proper absorption.
C. Flushing the tube with 2 mL of sterile water is insufficient after all medications are administered. Typically, the tube should be flushed with 15-30 mL of water before and after medication administration to ensure patency.
D. Mixing all medications together is not recommended because different medications may have incompatible properties, and mixing them could alter their effectiveness or cause adverse reactions. Each medication should be administered separately.
Correct Answer is D
Explanation
A. Hypersomnia is not typically associated with Cushing's syndrome. Instead, individuals with Cushing's syndrome often experience insomnia or sleep disturbances.
B. Hypotension is not a common finding in Cushing's syndrome. The condition typically leads to hypertension due to increased cortisol levels, which raise blood pressure.
C. Rapid weight loss is not characteristic of Cushing's syndrome. In fact, Cushing's syndrome typically causes rapid weight gain, especially in the trunk and face.
D. Rounded facial features, also known as a "moon face," are a hallmark sign of Cushing's syndrome, caused by an increase in cortisol and fat deposition in the face.
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