A nurse is planning to administer an IM injection into a client's deltoid muscle. Which action should the nurse take?

Inject a volume of less than 2 mL.

Inject the medication at a 90 degree angle.

Inject the medication 12.7 cm (5 in) below the client's acromion process.

Use a 21-gauge needle for the injection.

Answer and Explanation

The Correct Answer is B

A) Inject a volume of less than 2 mL: While it is generally recommended to inject a volume of less than 2 mL into the deltoid muscle to avoid discomfort and ensure proper absorption, this is not the primary action to focus on when planning the injection.

B) Inject the medication at a 90 degree angle: This is the correct action. Administering an intramuscular (IM) injection at a 90-degree angle ensures that the medication is delivered deep into the muscle tissue, which is necessary for proper absorption and effectiveness.

C) Inject the medication 12.7 cm (5 in) below the client’s acromion process: The correct injection site for the deltoid muscle is typically 2-3 finger widths (approximately 2.5-5 cm) below the acromion process, not 12.7 cm. Injecting too far below the acromion process could result in an incorrect injection site.

D) Use a 21-gauge needle for the injection: While a 21-gauge needle can be used for IM injections, the gauge of the needle is not the primary focus in this context. The angle of injection is more critical to ensure proper delivery of the medication.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Encourage elderly clients to keep a list of all medications, including dose and frequency, with them at all times:
Maintaining an accurate list of all medications, including doses and frequencies, helps prevent polypharmacy by ensuring that healthcare providers have a complete picture of what the patient is taking. This list can be critical in preventing drug interactions, avoiding duplicate therapies, and ensuring that the patient does not inadvertently take conflicting medications. It also aids in coordinating care among multiple providers.

B. Provide only written instructions for medications to elderly clients:
While written instructions are helpful, relying solely on them may not be sufficient. Elderly clients may have difficulty reading or understanding written instructions due to various factors like visual impairments or cognitive decline. A comprehensive approach, including verbal instructions and opportunities for clarification, is often more effective.

C. Encourage patients to use multiple pharmacies for convenience:
Using multiple pharmacies can increase the risk of polypharmacy because it may lead to a lack of coordination and awareness of all the medications the patient is taking. A single pharmacy or a centralized medication management system is generally more effective in tracking and managing medications to avoid interactions and duplications.
D. Teach elderly clients to have a spouse or family member be responsible for all of their medications:
While involving family members in medication management can be beneficial, it is not a strategy to prevent polypharmacy. The primary responsibility for managing medications should lie with the patient, in collaboration with healthcare providers, to ensure accuracy and understanding. Family members can assist, but they should not replace the need for personal medication management and monitoring.

A. Naloxone B. Flumazenil C. Protamine D. Epinephrine

Correct Answer is A

Explanation

A) Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. Given that the client has overdosed on morphine and is exhibiting a critically low respiratory rate of 6/min, naloxone is the appropriate medication to administer to reverse the effects of morphine and restore normal breathing.

B) Flumazenil: Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepine overdose. It is not effective for opioid overdoses, such as those caused by morphine.

C) Protamine: Protamine is used to reverse the effects of heparin, an anticoagulant, and is not relevant in the context of opioid overdose. It does not address the respiratory depression caused by morphine.

D) Epinephrine: Epinephrine is used in cases of anaphylaxis or severe allergic reactions and is not appropriate for reversing opioid overdose. It would not address the respiratory depression caused by morphine overdose.

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A nurse is planning to administer an IM injection into a client's deltoid muscle. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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