A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?

Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest.

Measure two fingerbreadths below the acromion process.

Ensure to find a place 2 inches away from the umbilicus and free of bruising.

Measure a handbreadth above the knee and a handbreadth below the greater trochanter.

Answer and Explanation

The Correct Answer is D

A. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest: This method is used to locate the ventrogluteal site, not the vastus lateralis.

B. Measure two fingerbreadths below the acromion process: This technique is used to identify the deltoid muscle for IM injections. It is not appropriate when the vastus lateralis is the intended site for medication administration.

C. Ensure to find a place 2 inches away from the umbilicus and free of bruising: This description refers to a subcutaneous injection in the abdomen, commonly used for medications like insulin or heparin, not for IM injections.

D. Measure a handbreadth above the knee and a handbreadth below the greater trochanter: This is the correct technique for locating the vastus lateralis muscle. It ensures the injection is given in the thickest part of the muscle, minimizing the risk of nerve or blood vessel injury.

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Correct Answer is C

Explanation

A. Increased balance: Aging typically results in decreased balance due to changes in the musculoskeletal and nervous systems. Older adults often experience a decline in coordination and proprioception, which can increase the risk of falls.

B. Increased muscle mass: Muscle mass generally decreases with age, a condition known as sarcopenia. This loss contributes to reduced strength and endurance, making physical activity and mobility more difficult for older adults.

C. Increased joint stiffness: Joint stiffness is a common age-related change caused by decreased synovial fluid, cartilage wear, and reduced flexibility. This can limit mobility and make daily activities more challenging for elderly clients.

D. Increased calcification of bones: With aging, bones tend to lose density and become more porous, leading to conditions like osteoporosis. Calcification may occur in soft tissues, but bone itself typically becomes weaker, not more calcified.

A. Complete the task quickly, then obtain PPE. B. Stop and obtain appropriate PPE. C. Ask a colleague to perform the task. D. Leave PPE in the room for the next person.

Correct Answer is B

Explanation

A. Complete the task quickly, then obtain PPE: This action risks exposure to infectious agents and violates infection control protocols. Speed does not justify unsafe practice.

B. Stop and obtain appropriate PPE: The nurse should immediately stop the task and put on the necessary PPE to protect themselves and prevent the spread of infection before proceeding.

C. Ask a colleague to perform the task: Transferring the task does not address the nurse’s responsibility to maintain safety and infection control. The nurse must follow proper protocols personally.

D. Leave PPE in the room for the next person: PPE should be donned and doffed properly for each use and not left unattended or assumed to be for others’ use, which can lead to contamination or improper use.

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A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?

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A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?