A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Select a 1-inch needle.

Use a 45° angle when inserting the needle.

Use the ventrogluteal site.

Pinch the skin up during injection.

Answer and Explanation

The Correct Answer is C

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.

B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.

C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.

D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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Correct Answer is ["A","B","C"]

Explanation

A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.

B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.

C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.

D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.

E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.

A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report this to the nurse manager." C. "Have you thought about how your extended lunch breaks affect the other members of our team?" D. "Did you inform the other members of your team about when you left and returned from break?"

Correct Answer is A

Explanation

A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.

B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.

C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.

D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.

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A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

Correct Answer is A

Explanation

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