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 A
Explanation
A. A 5 mL syringe can hold up to 5 mL of fluid. It is suitable for administering 2 mL of medication, as it provides enough capacity with some additional space to ensure accurate measurement and prevent overfilling.
B. A 1 mL syringe is too small for administering a 2 mL injection. It would not accommodate the entire volume, and attempting to draw and administer 2 mL with a 1 mL syringe could result in spillage or inaccurate dosing.
C. A 10 mL syringe is larger than necessary for administering a 2 mL injection. While it can hold the required volume and more, it is bulkier and might be less convenient for administering smaller volumes like 2 mL.
D. A 3 mL syringe can also accommodate a 2 mL injection. However, a 5 mL syringe would provide a more appropriate capacity with a bit of extra space, which can be beneficial for accurate measurement and ease of administration.
Correct Answer is B
Explanation
B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.
A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.
C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.
D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.
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