The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?
Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular injection.
Divide the medication into two injections with volumes under 1 mL.
Administer into the deltoid muscle while the parent holds the infant securely.
Use a quick dart-like motion to inject into the dorsogluteal site.
The Correct Answer is B
Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.
In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.
Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Anal abscesses and fistulas are more commonly associated with Crohn's disease than with ulcerative colitis. Crohn's disease can involve the entire thickness of the bowel wall and create tunnels or connections (fistulas) between different parts of the gastrointestinal tract.
B) Correct- Rectal bleeding is a common symptom of ulcerative colitis, as the inflamed tissue can bleed easily.
C) Incorrect- Constipation is not a common characteristic of Crohn's disease. In fact, both ulcerative colitis and Crohn's disease can lead to a range of bowel habits, including diarrhea and constipation, depending on the extent and location of inflammation.
D) Incorrect- Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases (IBD) that involve chronic inflammation of the gastrointestinal tract. Ulcerative colitis primarily affects the colon and rectum, causing continuous areas of inflammation and ulceration. Crohn's disease can affect any part of the gastrointestinal tract, from the mouth to the anus. It often involves patches of inflammation with healthy tissue in between, and it can affect different layers of the bowel wall.
Correct Answer is ["B","D","E"]
Explanation
These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.
Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.
Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.
Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.
While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.
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