A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?
Inject the medication 12.7 cm (5 in) below the client's acromion process
Use a 21-gauge needle for the injection
Inject the medication at a 90-degree angle
Inject a volume of less than 2 mL
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 C
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.