A nurse is preparing to administer an IM injection to a preschool-age child.
Which of the following actions should the nurse take?

Tell the child the medicine will make him feel better.

Ask the parents to hold the child.

Allow the child to hold a favorite toy.

Administer the medication in the child’s room.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While it’s important to explain to a child why they are receiving medication, simply telling them that it will make them feel better may not be enough to alleviate their fear or anxiety about receiving an injection.

Choice B rationale

Asking the parents to hold the child during an injection can be traumatic for both the child and the parent. It’s generally recommended to have a trained healthcare professional hold the child in a safe and secure manner.

Choice C rationale

Allowing the child to hold a favorite toy can provide comfort and distraction during the injection.

Choice D rationale

While it might seem like a good idea to administer the medication in the child’s room where they feel safe, this can actually make the child associate their safe space with negative experiences.

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Correct Answer is D

Explanation

Choice A rationale

Removing elbow restraints while the infant is sleeping is not a recommended intervention following cleft palate repair. Elbow restraints are used to prevent the infant from touching the surgical site and potentially causing injury or infection. Therefore, they should not be removed while the infant is sleeping.

Choice B rationale

Keeping the infant in a side-lying position is not a specific recommended intervention following cleft palate repair. The position of the infant following surgery will depend on various factors, including the infant’s comfort and the surgeon’s instructions.

Choice C rationale

Feeding the infant half-strength formula for the first 48 hours is not a specific recommended intervention following cleft palate repair. The infant’s feeding regimen following surgery will depend on various factors, including the infant’s age, weight, and overall health, as well as the surgeon’s instructions.

Choice D rationale

Administering pain medication PRN (as needed) for the first 48 hours is a recommended intervention following cleft palate repair. Pain management is an important part of postoperative care, and appropriate pain medication can help ensure the infant’s comfort and promote healing.

A. Lethargy. B. Respiratory rate 20/min. C. Lying flat on the unaffected side. D. Urine output 50 mL in 2 hr. .

Correct Answer is A

Explanation

Choice A rationale

Lethargy in a child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt could indicate a serious problem such as shunt malfunction or infection, and should be the priority.

Choice B rationale

A respiratory rate of 20/min is within the normal range for a 4-year-old child and is not typically a cause for concern.

Choice C rationale

Lying flat on the unaffected side is not typically a cause for concern following ventriculoperitoneal shunt surgery.

Choice D rationale

A urine output of 50 mL in 2 hr is within the normal range for a 4-year-old child and is not typically a cause for concern.

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A nurse is preparing to administer an IM injection to a preschool-age child.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair.Which of the following interventions should the nurse contribute to the client’s plan of care?

Correct Answer is D

Explanation

A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt.Which of the following findings should the nurse identify as the priority?

Correct Answer is A

Explanation

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A nurse is preparing to administer an IM injection to a preschool-age child.
Which of the following actions should the nurse take?