A nurse is preparing to administer scheduled vaccines to a 5-year-old child. Which of the following measures should the nurse take?

Perform the intramuscular (IM) injections slowly.

Apply a topical anesthetic.

Place client in supine position.

Inject the most painful vaccine first.

Answer and Explanation

The Correct Answer is B

A. Perform the intramuscular (IM) injections slowly: Rapid injection can increase pain and tissue trauma, but slowing the injection alone is not the primary evidence-based strategy for minimizing pain in pediatric vaccinations. Other interventions, such as topical anesthetics or distraction techniques, are more effective in reducing procedural pain.

B. Apply a topical anesthetic: Topical anesthetics, such as lidocaine-prilocaine cream, are recommended for children to numb the injection site before IM vaccinations. Applying the anesthetic 30–60 minutes prior to the injection decreases pain and anxiety, improves cooperation, and supports a positive vaccination experience, making it an essential measure.

C. Place client in supine position: For IM injections, children older than infants are typically seated upright or held securely by a caregiver to allow proper access to the injection site and reduce fear. Supine positioning is less appropriate for a 5-year-old and may increase distress rather than improve safety or comfort.

D. Inject the most painful vaccine first: Evidence suggests that administering the least painful vaccine first can reduce overall distress, as children experience less anticipatory anxiety. Giving the most painful injection first may increase fear and resistance to subsequent injections, making it a less effective strategy for managing procedural pain.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will wipe off the yellow drainage each time I change my baby's diaper.": The yellow exudate that forms after circumcision is a normal part of healing and serves as a protective layer over the glans. Wiping it off can disrupt healing and increase the risk of irritation or infection. Parents should be instructed to leave the exudate intact.

B. "I will clean my baby's penis with alcohol after each diaper change.": Alcohol is harsh and can cause significant pain and tissue irritation on the circumcision site. It is contraindicated for post-circumcision care. Gentle cleaning with warm water is recommended instead to maintain hygiene without damaging healing tissue.

C. "I will apply petroleum to my baby's penis with each diaper change.": Applying petroleum jelly to the circumcision site protects the glans from friction with the diaper, reduces pain, and promotes healing. This is the correct and evidence-based method for routine post-Gomco circumcision care.

D. "I will use the diaper to apply gentle pressure to the area.": Applying pressure directly with the diaper can cause discomfort, increase the risk of tissue trauma, and interfere with proper healing. Care should focus on gentle hygiene and protective measures rather than using the diaper as a compress.

A. Use metaphors to help express meaning. B. Ask the client's family members to assist the interpreter. C. Direct all information to the client. D. Include medical terminology when explaining the procedure.

Correct Answer is C

Explanation

A. Use metaphors to help express meaning: Using metaphors can introduce confusion when working through an interpreter, as cultural and linguistic differences may cause misinterpretation. Medical explanations should be clear, simple, and literal to ensure the client accurately understands the information.

B. Ask the client's family members to assist the interpreter: Family members should not serve as interpreters for medical explanations. Using untrained interpreters can lead to errors, breaches of confidentiality, and incomplete or inaccurate information. Professional medical interpreters ensure accurate communication and patient safety.

C. Direct all information to the client: When using a medical interpreter, the nurse should address all information directly to the client, not the interpreter. This approach maintains respect for the client, promotes engagement, and ensures that the client is the focus of the teaching, while the interpreter facilitates communication.

D. Include medical terminology when explaining the procedure: Excessive medical terminology can confuse clients, especially when translation is involved. The nurse should use plain language, explain terms in simple words, and avoid jargon to ensure comprehension through the interpreter.

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Body System	Findings
integumentary	Skin feels cool to the touch Capillary refill 3 seconds in left foot. Dressing on left hand shows small amount of moisture through gauze
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter.

A nurse is preparing to administer scheduled vaccines to a 5-year-old child. Which of the following measures should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the parent of a newborn who underwent a circumcision using the Gomco method. Which of the following statements by the parent indicates an understanding of teaching?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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