Nokea
A 2-year-old child is to receive ear drops. The nurse is teaching the parent about giving the ear drops. Which instruction is appropriate?
- A. Administer the drops without pulling on the ear lobe.
- B. Straighten the ear canal by pulling the lobe upward and back.
- C. Straighten the ear canal by pulling the pinna down and back.
- D. Straighten the ear canal by pulling the pinna upward and outward.
Correct Answer: C
Rationale: For children under 3 years, pulling the pinna down and back straightens the ear canal for proper ear drop administration. The other methods are incorrect for this age group.
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After administering an intradermal (ID) injection for a skin test, the nurse notices a small bleb at the injection site. Which of these is the best action for the nurse to take at this time?
- A. Apply heat.
- B. Massage the area.
- C. Do nothing.
- D. Report the bleb to the physician.
Correct Answer: C
Rationale: A small bleb is an expected outcome after an intradermal injection for skin testing, indicating proper administration. No further action is needed.
The nurse has an order to administer an intramuscular (IM) immunization to a 2-month-old child. Which site is considered the best choice for this injection?
- A. Deltoid
- B. Dorsogluteal
- C. Ventrogluteal
- D. Vastus lateralis
Correct Answer: D
Rationale: The vastus lateralis is the preferred site for IM injections in infants due to its adequate muscle mass and lack of major nerves or blood vessels. The deltoid is used for older children and adults, the dorsogluteal site is not recommended due to nerve injury risk, and the ventrogluteal is preferred for adults and older children.
The nurse is about to give a rectal suppository to a patient. Which technique would facilitate the administration and absorption of the rectal suppository?
- A. Having the patient lie on the right side, unless contraindicated
- B. Having the patient hold his or her breath during insertion of the medication
- C. Lubricating the suppository with a small amount of petroleum-based lubricant before insertion
- D. Encouraging the patient to lie on the left side for 15 to 20 minutes after insertion
Correct Answer: D
Rationale: Positioning the patient on the left side and using a water-soluble lubricant facilitates insertion and absorption of a rectal suppository. The patient should remain on the left side for 15-20 minutes. Petroleum-based lubricants are not used, and breath-holding is not necessary.
When administering medication by IV bolus (push), the nurse will occlude the IV line by which method?
- A. Injecting the bolus without pinching the tubing
- B. Pinching the tubing just above the injection port
- C. Pinching the tubing just below the injection port
- D. Pinching the tubing just above the drip chamber of the infusion set
Correct Answer: B
Rationale: Occluding the IV line by pinching the tubing just above the injection port prevents backflow and ensures the medication is delivered correctly during an IV bolus. The other methods are incorrect.
The nurse is preparing to give an aqueous intramuscular (IM) injection to an average-sized adult. Which actions are appropriate? (Select all that apply.)
- A. Choose a 26- or 27-gauge, 1/4 to 1/2-inch needle.
- B. Choose a 20- to 25-gauge, 1- to 1 1/2-inch needle.
- C. Choose the dorsogluteal site, the preferred site for IM injections for adults.
- D. Insert the needle at a 45-degree angle.
- E. Insert the needle at a 90-degree angle.
- F. Before injecting the medication, withdraw the plunger to check for blood return.
Correct Answer: B,E,F
Rationale: For IM injections in adults, use a 20- to 25-gauge, 1- to 1 1/2-inch needle, insert at a 90-degree angle, and check for blood return to avoid intravascular injection. The dorsogluteal site is not preferred due to nerve risks; the ventrogluteal site is recommended. A 26- or 27-gauge needle is too small, and a 45-degree angle is for subcutaneous injections.