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What is the nurse's most effective response?
- A. No. It is over before you know it.'
- B. Yes. It will sting a little.'
- C. No. Would you like to see the syringe?'
- D. Yes. Your mom and I are going to hold you to help you be still.'
Correct Answer: B
Rationale: A truthful response about a slight sting builds trust and prepares the child for the IM injection.
You may also like to solve these questions
How would the nurse position the auricle when administering the ear drops?
- A. Up and back
- B. Down and back
- C. Up and out
- D. Down and out
Correct Answer: A
Rationale: For children 3 years and older, pulling the auricle up and back straightens the ear canal for effective ear drop administration.
What should be the next action by the nurse?
- A. Give the medication after confirming the child's name from the foot of the crib.
- B. Ask the charge nurse to give the medicine.
- C. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.
- D. Delay the medication until the admissions office can supply a new ID bracelet.
Correct Answer: C
Rationale: Confirming identity with the charge nurse and making a new bracelet ensures safe medication administration.
How would the nurse record the infant's urine output?
- A. 47 mL
- B. 44.5 mL
- C. 43.5 mL
- D. 40.5 mL
Correct Answer: B
Rationale: Subtracting the dry diaper weight (2.5 g) from the wet diaper weight (47 g) yields 44.5 mL of urine output.
What statement made by the adolescent led the nurse to determine she understood the instructions?
- A. I should wash my perineum with soap and water, then begin to urinate.'
- B. I clean the perineum from front to back with an antiseptic wipe before I urinate.'
- C. I'll collect the first stream of urine in a sterile container.'
- D. I will discard the first void and collect a freshly voided specimen 30 minutes later.'
Correct Answer: B
Rationale: Cleaning the perineum from front to back with an antiseptic wipe ensures a clean-catch urine specimen.
What initial position will the nurse maintain for this patient?
- A. Left side-lying
- B. Supine
- C. Prone
- D. Semi-Fowler's
Correct Answer: B
Rationale: Lying supine post-lumbar puncture helps prevent headaches by maintaining spinal fluid pressure.