Nokea
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
- B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- C. Administer the injection into the middle of the lateral aspect of the thigh.
- D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
Correct Answer: C
Rationale: The lateral thigh is the recommended IM injection site for toddlers, minimizing nerve and vessel damage.
You may also like to solve these questions
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Has doubled birth weight.
- B. Plays 'peek-a-boo.'
- C. Demonstrates startle reflex.
- D. Turns head to locate sound.
Correct Answer: C
Rationale: The startle reflex typically disappears by 3-4 months; its presence at 6 months may indicate a developmental or neurological issue.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Speaks in simple sentences with four or more words.
- B. Recognizes most letters and numbers.
- C. Uses gestures with 1-to-2-word sentences.
- D. Uses 1-word sentences.
Correct Answer: A
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.