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. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.
A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.
B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.
C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.
Correct Answer is C
Explanation
A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.
B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.
C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.
D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.
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