Answer to Question 1
C
Feedback:
To avoid the risk of damaging the radial nerve and artery in the deltoid site, the nurse should draw an imaginary line at the axilla first and then inject between the acromion and brachial vessels. The nurse should ask the client to lie down, sit, or stand with the shoulder well exposed. Pulling the tissue until it is taut and aspirating blood return from the tissue is part of the Z-track method, not part of the technique used to avoid the risk of damaging the radial nerve and artery.
Answer to Question 2
B
Feedback:
The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.
The nurse conducts the health history as the first step in the nursing assessment
A, A nurse is adding a medication to an IV line as a piggyback
The nurse applies a pulse oximeter sensor on the client’s finger.
A nurse administers an intermittent bolus feeding.
deltoid
(A) Unwrap each of the layers until the client is covered by just the plastic sheet and the towels ...