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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Using a filter needle is indeed a recommended practice when withdrawing medication from an ampule. This is because filter needles are designed to prevent glass particles from being drawn into the syringe after breaking the ampule.
B. Ampules should not be bent to open them. The proper method involves using a gauze or an ampule opener to snap the neck of the ampule away from the body. Bending the ampule can lead to shards of glass, risking injury to the nurse or contamination of the medication.
C. The ampule should be tapped gently to ensure all medication is in the lower portion before opening.
D. Withdrawing medication from the center of the ampule is the correct action because it ensures that the needle does not touch the broken glass edges, which could contaminate the medication or dull the needle.
Correct Answer is A
Explanation
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
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