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)
Dorsogluteal.
Abdomen.
Ventrogluteal.
Vastus lateralis.
Deltoid
Correct Answer : C,D,E
Choice A rationale
The dorsogluteal site is generally not recommended for intramuscular injections of 2.5 mL, especially in children or patients with less developed muscle mass, due to the significant risk of sciatic nerve injury and variable muscle depth. Ventrogluteal is preferred for larger volumes.
Choice B rationale
The abdomen is primarily used for subcutaneous injections, not intramuscular injections due to its composition primarily of adipose tissue and lack of substantial muscle mass. Injecting 2.5 mL intramuscularly into the abdomen would be painful, ineffective, and potentially harmful.
Choice C rationale
The ventrogluteal site is a safe and preferred intramuscular injection site, capable of accommodating volumes up to 2.5 mL due to its thick gluteus medius and minimus muscles, far from major nerves and blood vessels, reducing the risk of complications.
Choice D rationale
The vastus lateralis muscle is a large, well-developed muscle, making it a suitable site for intramuscular injections of 2.5 mL, particularly in adults and children. Its accessibility and distance from major nerves make it a safe option for medication administration.
Choice E rationale
The deltoid muscle can accommodate intramuscular injections of up to 2 mL in adults, making it an acceptable site for 2.5 mL if the muscle mass is adequately developed. However, care must be taken to avoid the radial nerve and ensure proper needle length.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The head-to-toe format does not exclude unnecessary body systems; rather, it aims to systematically include all major body systems to ensure a comprehensive assessment. Excluding systems could lead to missed findings and an incomplete understanding of the patient's health status. A thorough examination requires a complete survey, even if initial symptoms point to a specific area, to identify any related or unrelated issues.
Choice B rationale
A head-to-toe approach provides a structured and systematic method for examining all body systems. This ensures that no area is overlooked, promoting a comprehensive data collection process. It allows for a logical flow, minimizing omissions and facilitating the identification of interconnections between different bodily functions. This organization enhances efficiency and thoroughness in clinical assessment.
Choice C rationale
The head-to-toe approach does not mandate that painful procedures be done first. In fact, best practice dictates that painful or uncomfortable assessments should generally be deferred until the end of the examination to maintain patient cooperation and trust. Starting with non-painful assessments allows the patient to acclimate and reduces anxiety, improving the overall quality of the examination.
Choice D rationale
A head-to-toe assessment does not reduce time by examining only one side of the body. A comprehensive physical examination requires bilateral assessment of most structures and systems to identify asymmetries or unilateral abnormalities. Limiting the examination to one side would provide an incomplete and potentially misleading clinical picture. Full evaluation ensures all relevant data are collected.
Correct Answer is C
Explanation
Choice A rationale
Comparison is a broad principle of assessment, but "side-to-side" describes the specific methodical approach for auscultation. While comparison is the underlying goal, the physical act involves moving systematically between corresponding areas. Relying solely on a general comparison without a structured sequence can lead to omissions in assessment.
Choice B rationale
Progressing from anterior to posterior in one continuous sweep can lead to missed areas and a less systematic comparison of lung fields. Effective auscultation necessitates a structured approach that allows for direct comparison of symmetric areas, ensuring that subtle differences in breath sounds or adventitious sounds between sides are accurately identified.
Choice C rationale
The side-to-side method facilitates direct comparison of breath sounds between symmetrical lung fields, which is crucial for identifying unilateral abnormalities. This systematic approach ensures that each segment of the lung is assessed in relation to its contralateral counterpart, allowing for prompt detection of differences in air entry, quality, or presence of adventitious sounds.
Choice D rationale
While auscultating interspace by interspace is part of the technique, the overarching method for comparing sounds and ensuring comprehensive coverage is the side-to-side progression. Auscultating individual interspaces sequentially without direct contralateral comparison reduces the ability to identify subtle unilateral changes in lung sounds effectively.
Choice E rationale
A top-to-bottom approach, without consistent side-to-side comparison, can lead to inefficiencies and potential oversight of localized abnormalities. While auscultation generally proceeds superiorly to inferiorly, the critical aspect is the bilateral comparison at each corresponding level to detect subtle variations in breath sounds and identify pathology accurately.
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