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A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?

A.

Inject the medication 12.7 cm (5 in) below the client's acromion process

B.

Use a 21-gauge needle for the injection

C.

Inject the medication at a 90-degree angle

D.

Inject a volume of less than 2 mL

Answer and Explanation

The Correct Answer is D

A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.  

 

B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.  

 

C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.  

 

D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.


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Correct Answer is B

Explanation

A. Peanuts contain protein but also have a higher fat content, making them less optimal compared to lean meats.

B. Chicken is an excellent source of high-quality protein, providing essential amino acids with lower fat content, making it the best recommendation among the options listed.

C. Yams are primarily a carbohydrate source and do not significantly contribute to protein intake.

D. Eggs are a good source of protein, but chicken typically provides more protein per serving, making it the superior choice for increasing protein intake.

Correct Answer is A

Explanation

A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.

B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.

C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.

D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.

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