A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Increased blood pressure

Thready pulse

Dyspnea

Decreased heart rate

Answer and Explanation

The Correct Answer is B

A. Increased blood pressure: Hypovolemia typically causes a decrease in blood pressure, not an increase.
B. Thready pulse: A thready pulse is a common sign of hypovolemia due to decreased blood volume.
C. Dyspnea: While dyspnea can occur, it is not as specific as a thready pulse for hypovolemia.
D. Decreased heart rate: Hypovolemia usually causes an increased heart rate as the body tries to compensate for low blood volume.

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Correct Answer is C

Explanation

A. Select a 5/8-inch needle: A 5/8-inch needle is too short for an IM injection in an adult, as it may not reach the muscle tissue adequately.
B. Choose a 25-gauge needle: A 25-gauge needle is too small for an IM injection, as it may make the administration of a 3 mL volume difficult and painful.
C. Locate the ventrogluteal site: The ventrogluteal site is a preferred site for IM injections because it is free of major nerves and blood vessels and can accommodate larger volumes like 3 mL.
D. Inject at a 45° angle: IM injections should be administered at a 90° angle to ensure the medication is delivered into the muscle tissue.

A. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. B. Locate the center of the arm between the elbow and the shoulder. C. Find the center of the anterior aspect of the thigh. D. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.

Correct Answer is A

Explanation

A. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. This is the correct method to locate the deltoid muscle for an intramuscular injection.
B. Locate the center of the arm between the elbow and the shoulder. This method does not accurately locate the deltoid muscle and may lead to incorrect injection placement.
C. Find the center of the anterior aspect of the thigh: This method locates the vastus lateralis muscle, not the deltoid muscle.
D. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.: This method locates the vastus lateralis muscle, not the deltoid muscle.

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A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

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