A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?
Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.
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.
Find the center of the anterior aspect of the thigh.
Locate the center of the arm between the elbow and the shoulder.
The Correct Answer is B
B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.
A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.
C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.
D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.
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Related Questions
Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is A
Explanation
A. 0.9% sodium chloride (normal saline) is isotonic, meaning it has the same concentration of solutes as blood plasma. It is used to expand intravascular volume and replace fluids and electrolytes.
B. "Hypnotic" refers to medications that induce sleep and has no relevance to IV solutions. This term does not apply to IV solutions.
C. A hypotonic solution has a lower concentration of solutes compared to normal body fluids. Examples include 0.45% sodium chloride (half-normal saline) or 5% dextrose in water (D5W). 0.9% sodium chloride (normal saline) is not hypotonic; rather, it is isotonic.
D. A hypertonic solution has a higher concentration of solutes compared to normal body fluids. Examples include 3% sodium chloride or 5% dextrose in 0.9% sodium chloride. 0.9% sodium chloride (normal saline) is not hypertonic; rather, it is isotonic.
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