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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.
B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.
C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.
D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.
Correct Answer is C
Explanation
A. Children with autism may have difficulty with social interactions and sensory processing. Placing them in a semiprivate room could cause distress due to the lack of control over the environment and may increase anxiety.
B. Maintaining eye contact with a child with autism, especially when agitated, may increase stress and exacerbate agitation. Many children with autism avoid eye contact and may find it uncomfortable.
C. Children with autism can be very sensitive to sensory input, including physical touch. Minimizing physical contact helps reduce sensory overload and the child’s anxiety.
D. While providing comforting stimuli can be beneficial, leaving the television on at night may disturb the child’s sleep or increase sensory overload, especially if they are sensitive to sounds or visual stimuli.
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