The nurse is preparing to administer a dose of promethazine IM. When pulled up in the syringe, the needle contains 2.5 mL of medication.
The nurse is aware that the medication can be given in which sites. (SELECT 3 CORRECT OPTIONS)

Choice A rationale

Administering only 0.5 mL subcutaneously is a common volume for certain medications, but it is not the maximum. Larger volumes can sometimes be administered, depending on the site and medication characteristics, without causing undue tissue distention or discomfort.

Choice B rationale

The subcutaneous tissue layer has a limited capacity for fluid absorption, and volumes exceeding 1 mL can cause tissue distention, discomfort, and potentially impair absorption due to increased pressure. This volume minimizes local tissue irritation and ensures optimal medication uptake into the systemic circulation.

Choice C rationale

Administering 2 mL subcutaneously is generally discouraged due to the potential for significant tissue distention, discomfort, and pain. Such a large volume can also lead to poor absorption and increased risk of local adverse reactions, making it an impractical and often unsafe choice for routine subcutaneous injections.

Choice D rationale

While 1.5 mL is closer to the maximum, it often pushes the limits of comfortable and effective subcutaneous administration. This volume may cause considerable discomfort, particularly in clients with limited subcutaneous tissue, and can compromise absorption rates.

Choice A rationale

While documenting additional clothing could mitigate some error, the presence of a jacket and shoes adds variable, unmeasured mass. Accurate weight measurement is crucial for medication dosing, fluid balance assessment, and nutritional status monitoring. Even seemingly minor additions can significantly skew results, impacting clinical decisions and potentially leading to suboptimal patient care.

Choice B rationale

The type of scale significantly impacts accuracy and precision. Different scales, such as beam scales, electronic scales, or bed scales, have varying calibration standards and sensitivities. Using a consistent, properly calibrated scale minimizes measurement variability and ensures reliable data, which is essential for tracking trends and making valid comparisons over time in a clinical setting.

Choice C rationale

Diurnal variations in body weight occur due to factors like fluid shifts, food and fluid intake, and bowel elimination. Weighing at the same time minimizes these transient fluctuations, providing a more consistent and comparable baseline for monitoring weight changes over time. This consistency is vital for accurate assessment of a patient's fluid status, nutritional progress, or response to therapeutic interventions.

Choice D rationale

While weighing in undergarments provides the most accurate baseline, it may not always be practical or appropriate due to patient comfort, privacy concerns, or clinical urgency. The goal is to standardize the weighing procedure as much as possible, including minimizing clothing and documenting any deviations to ensure consistency and interpretability of serial weight measurements.