Author Question: A nurse needs to administer an intramuscular injection to a client in the deltoid site. Which of the ... (Read 53 times)

mikaylakyoung · **on:** Jul 22, 2018

A nurse needs to administer an intramuscular injection to a client in the deltoid site. Which of the following actions will reduce the risk of damaging the client's radial nerve or artery?

A) Avoid asking the client to lie down or sit.
B) Aspirate for blood return from the tissue.
C) Draw an imaginary line at the axilla between the acromion and brachial vessels.
D) Pull the tissue laterally until it is taut.

Question 2

During an assessment of an elderly client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure.

The nurse recognizes that what medical diagnosis may be responsible? A) Hypervolemia
B) Hypovolemia
C) Edema
D) Circulatory overload

miss_1456@hotmail.com · **Reply #1 on:** Jul 22, 2018

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.