The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a six-month-old infant
To administer this injection safely, the nurse chooses which of the following needles (size and length), injection type, and injection site? 1. 25-gauge, 5/8-inch needle; IM (intramuscular); anterolateral thigh
2. 25-gauge, 5/8-inch needle; ID (intradermal); deltoid
3. 22-gauge, 1/2-inch needle; IM (intramuscular); dorsogluteal
4. 25-gauge, 3/4-inch needle; SQ (subcutaneous); anterolateral thigh
1
Rationale 1: This vaccine is only given SQ to infants, not IM.
Rationale 2: Infants do not receive medication/vaccines in the deltoids.
Rationale 3: A 22-gauge needle is too big for infants, and injections should not be given in the dorsogluteal site.
Rationale 4: The dose of DTaP is 0.5 cc or 0.5 mL, to be given with a 22 to 25-gauge, 5/8—3/4-inch needle; IM (intramuscularly). The anterolateral thigh is safe to use for this age infant. Research has shown that the ventrogluteal site also may be used safely for this age infant.
Global Rationale:
You might also like to view...
A patient has had left-sided lumpectomy (breast-conservation surgery) and an axillary lymph node dissection. Which nursing intervention is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)?
a. Teaching the patient how to avoid injury to the left arm b. Assessing the patient's range of motion for the left arm c. Evaluating the patient's understanding of instructions about drain care d. Administering an analgesic 30 minutes before scheduled arm exercises
The licensed vocational nurse/licensed practical nurse (LPN/LVN) knows that his or her scope of practice includes all of the following except:
A) Administering nursing care under the direction of a registered nurse (RN) B) Documenting the patient's data C) Independently ordering medications for the patient D) Assisting the physician or registered nurse with more complex care and procedures
A middle-aged construction worker has a raised lesion with a pearly border on his arm that bleeds easily. The nurse realizes that this client most likely is experiencing a(n):
1. actinic keratosis. 2. basal cell carcinoma. 3. malignant melanoma. 4. melanoma in situ.
In health, urine pH is between:
a. 1.5 and 4.5. b. 3.5 and 5.5. c. 4.5 and 8.0. d. 6.5 and 9.5.