A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client.
Which of the following is the safest site for the nurse to use?

Ventrogluteal

Dorsogluteal

Vastus lateralis

Rectus femoris

Answer and Explanation

The Correct Answer is A

A. Ventrogluteal - The ventrogluteal site is preferred for intramuscular injections in adults due to its proximity to large, deep muscles and minimal risk of injury to major nerves and blood vessels.

B. Dorsogluteal - The dorsogluteal site is not recommended for intramuscular injections due to the risk of injury to the sciatic nerve and superior gluteal artery.

C. Vastus lateralis - The vastus lateralis is a safe site for intramuscular injections, particularly in infants and young children.

D. Rectus femoris - The rectus femoris muscle is not typically used for intramuscular injections due to its superficial location and proximity to major blood vessels.

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Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

A. Perform another internal exam. B. Notify the client's provider. C. Check the FHR. D. Obtain a pH test of the fluid.

Correct Answer is C

Explanation

A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.

B. Notifying the client's provider may be necessary, but it is not the immediate priority.

C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.

D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.

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A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client.Which of the following is the safest site for the nurse to use?

Nursing Test Bank

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Explanation

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A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client.
Which of the following is the safest site for the nurse to use?