Nokea
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.
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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.
A patient is to receive hydromorphone 1.5 mg IV push now. The medication comes in a prefilled syringe, 2 mg/mL. Identify how many milliliters the nurse will administer for this dose.
Correct Answer: 0.75 mL
Rationale: To calculate: 2 mg/1 mL = 1.5 mg/x mL. Cross-multiply: (2 * x) = (1 * 1.5); 2x = 1.5; x = 1.5/2 = 0.75 mL.
The nurse is giving an intradermal (ID) injection and will choose which syringe for this injection?
- A. interderm_1.PNG
- B. interderm_2.PNG
- C. interderm_3.PNG
- D. interderm_4.PNG
Correct Answer: B
Rationale: The proper size syringe for ID injection is a 1-mL tuberculin. The other syringes pictured are incorrect. Insulin syringes (marked in units) are not used for intradermal injections.
The nurse needs to administer insulin subcutaneously to an obese patient. Which is the proper technique for this injection?
- A. Using the Z-track method
- B. Inserting the needle at a 5- to 15-degree angle until resistance is felt
- C. Pinching the skin at the injection site, and then inserting the needle to below the tissue fold at a 90-degree angle
- D. Spreading the skin tightly over the injection site, inserting the needle, and then releasing the skin
Correct Answer: C
Rationale: For subcutaneous injections in obese patients, pinching the skin and inserting the needle at a 90-degree angle ensures delivery into the subcutaneous tissue. The Z-track method is for IM injections, a 5- to 15-degree angle is incorrect, and spreading the skin is not appropriate for subcutaneous administration.
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.