Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
16. A clinic nurse is preparing to administer several scheduled immunizations to a 6-month-old infant. What are the appropriate actions for the nurse to take when preparing and administering immunizations? Select all that apply.
. Draw vaccines into one syringe for injection.
. Administer injections in either vastus lateralis muscle.
. Administer injections in either dorsogluteal muscle.
. Ask the parent to wait outside the exam room.
. Select a 1-inch needle.
. Wash hands.
Test-Taking Tip
Recall that immunizations are intramuscular injections. The best site for injections in an infant is a well-developed muscle, such as the thigh.
Content Area: Child Health, Immunizations; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Immunizations
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because the nurse should not combine immunizations together in a syringe. Answer 2 is correct because the appropriate injection site for an infant is the thigh muscle. Answer 3 is incorrect because the dorsogluteal muscle is contraindicated for use in infants due to the risk of injury to the sciatic nerve. Answer 4 is incorrect because parents should be given the option to stay with the child during painful procedures. Answer 5 is correct since a 1-inch needle is appropriate for infants 4 months of age and older. This length allows the tip of the needle to penetrate deep into the muscle and avoids accidental administration into the subcutaneous tissue. A longer needle (e.g., 1½ inch) would be better for adults or older children who are significantly overweight. Answer 6 is correct since the nurse should first wash hands prior to any procedure.