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.
Aspirate for the presence of blood return prior to administering the vaccine.
Ensure the guardian signed a consent form for the immunization.
The Correct Answer is C
Choice A rationale
Massaging the injection site after administering a vaccine is generally not recommended as it may cause irritation or introduce bacteria to the site, increasing the risk of infection. Additionally, massaging the area does not improve the absorption or efficacy of the vaccine. Vaccines are designed to be absorbed effectively by the body without the need for additional manipulation. Healthcare professionals are trained to administer vaccines using techniques that minimize discomfort and ensure proper delivery of the vaccine into the muscle tissue.
Choice B rationale
Aspiration, or pulling back on the syringe plunger after inserting the needle but before injecting the vaccine, is not recommended when administering vaccines. Studies have shown that aspiration is unnecessary and may increase the risk of injury, pain, and prolonged injection time. The practice of aspiration is based on the outdated concern of inadvertently injecting the vaccine into a blood vessel. However, research indicates that the risk of this occurring is extremely low when proper injection techniques are used. The focus should be on delivering the vaccine quickly and efficiently to minimize discomfort.
Choice C rationale
Ensuring that the guardian has signed a consent form for immunization is an essential step in the vaccination process. Obtaining informed consent means that the guardian is aware of the potential benefits and risks associated with the vaccine and agrees to proceed with the vaccination. This practice is crucial for maintaining trust between healthcare providers and patients, respecting the rights of individuals to make informed healthcare decisions, and adhering to legal and ethical standards in medical practice. Proper documentation of consent is also important for record-keeping and future reference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding participation in school sports is not recommended for children with asthma. Regular physical activity is important for overall health, and with proper management, children with asthma can safely engage in sports. Exercise-induced asthma can be controlled with pre-exercise medication and an asthma action plan, allowing children to remain active without exacerbating their condition.
Choice B rationale
The correct technique for using a peak flow meter involves inhaling deeply and then exhaling quickly and forcefully, not inhaling deeply and quickly. This instruction is incorrect and could lead to improper use of the device, affecting the accuracy of peak flow measurements. Accurate use of the peak flow meter is essential for monitoring asthma control.
Choice C rationale
Pneumococcal immunization is recommended for children with asthma because they are at an increased risk of respiratory infections, which can trigger asthma exacerbations. The vaccine helps protect against pneumococcal bacteria, reducing the likelihood of serious respiratory complications and supporting overall asthma management.
Choice D rationale
Salmeterol is a long-acting beta-agonist used for the maintenance treatment of asthma. It is not intended for managing acute exacerbations. For acute asthma attacks, short-acting bronchodilators such as albuterol are recommended to provide quick relief of symptoms. Using salmeterol for acute exacerbations could result in inadequate asthma control.
Correct Answer is B
Explanation
Choice A rationale
Vesicles on the trunk are indicative of varicella (chickenpox) rather than respiratory syncytial virus (RSV). RSV typically causes respiratory symptoms rather than skin manifestations like vesicles.
Choice B rationale
Rhinorrhea (runny nose) is a common symptom of RSV in infants. It is part of the upper respiratory symptoms caused by the virus, alongside coughing and wheezing.
Choice C rationale
Barrel chest is more associated with chronic conditions like cystic fibrosis or severe, long-standing asthma, not acute infections like RSV. RSV primarily affects the bronchioles, leading to bronchiolitis.
Choice D rationale
Clubbing of the fingers is generally a sign of chronic hypoxia and is seen in long-term conditions such as congenital heart disease or cystic fibrosis, rather than acute RSV infection. .
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