The nurse is administering an intramuscular injection to a 9 month old infant. What is the preferred injection site?

gluteal maximus

deltoid

ventral gluteal

vastus lateralis

Answer and Explanation

The Correct Answer is D

Choice A rationale: The gluteal maximus is not a recommended site for intramuscular injections in infants due to the risk of injury to the sciatic nerve.

Choice B rationale: The deltoid muscle is a suitable site for older children and adults but may not be well-developed in infants.

Choice C rationale: The ventral gluteal site is not typically recommended for infants due to the potential risk of injury to the sciatic nerve.

Choice D rationale: The vastus lateralis muscle is the preferred injection site for intramuscular injections in infants.

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Correct Answer is C

Explanation

Choice A rationale: Pursed-lip breathing is a compensatory mechanism to improve oxygenation and is not as severe an indication as cyanosis.

Choice B rationale: Clubbing of the nails is a chronic sign of oxygenation issues but may not be an acute and immediate indication of deterioration.

Choice C rationale: Cyanosis, the bluish discoloration of the skin and mucous membranes, is a serious indication of inadequate oxygenation.

Choice D rationale: Poor skin turgor is not a direct indicator of oxygenation status.

A. Give the medication anyway because it's important for the client B. Withhold the medication and report it to the prescriber C. Withhold the medication and file an incident report D. Inform the client that the medication must be taken until the nurse gets an order to discontinue it

Correct Answer is B

Explanation

Choice A rationale: Administering the medication against the client's will is not respectful of the client's autonomy and right to make decisions about her own care.

Choice B rationale: Withholding the medication and reporting it to the prescriber is appropriate. The prescriber can reassess the situation and determine the next course of action.

Choice C rationale: Withholding the medication and filing an incident report may be premature; it is essential to involve the prescriber first.

Choice D rationale: Informing the client that the medication must be taken until the nurse gets an order to discontinue it may not be the best approach, as it does not respect the client's right to refuse treatment. The prescriber should be involved in the decision-making process.

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The nurse is administering an intramuscular injection to a 9 month old infant. What is the preferred injection site?

Nursing Test Bank

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