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A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

Find the center of the anterior aspect of the thigh.

Locate the center of the arm between the elbow and the shoulder.

Answer and Explanation

The Correct Answer is B

B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.

A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.

C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.

D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.

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Correct Answer is A

Explanation

A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.

B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.

C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.

D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.

A. Hold the syringe at a 20° angle to the client's skin. B. Draw up 0.5 mL of purified protein derivative (PPD) from the vial. C. Place a 1 in needle on the syringe. D. Hold the skin taut at the chosen site with the nondominant hand before inserting the needle.

Correct Answer is D

Explanation

D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.

A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.

B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.

C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.

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A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

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