The nurse is preparing to administer an IM injection to an adult client who weighs 200 pounds (90 kg). Which equipment is needed for this procedure? Select all that apply.
18 to 21 gauge needle.
1 inch needle.
23 to 25 gauge needle.
Sterile gloves.
5/8 inch needle.
Correct Answer : A,C,D
A. An 18 to 21 gauge needle is appropriate for administering viscous or oil-based medications intramuscularly. IM injections require delivery of the medication into the muscle tissue, which can sometimes necessitate a larger bore needle depending on the medication’s viscosity. Using the correct gauge ensures that the medication is delivered properly and prevents issues like clogging or tissue trauma.
B. A 1-inch needle is commonly used for average-weight adults, but for a client weighing 200 pounds (90 kg), the subcutaneous tissue may be thicker, particularly in areas like the deltoid or gluteal region. To ensure the medication reaches the muscle, a longer needle (e.g., 1.5 inches) is often required. Using a 1-inch needle may result in the medication being deposited in subcutaneous fat instead of muscle, which can reduce absorption and effectiveness.
C. A 23 to 25 gauge needle is commonly used for most IM injections that are not highly viscous. This gauge is suitable for delivering standard medications like vaccines or antibiotics with minimal discomfort while still ensuring intramuscular delivery. Nurses may select the gauge based on medication type, injection site, and patient comfort.
D. Sterile gloves are required to maintain aseptic technique and reduce the risk of introducing infection into the injection site. Gloves also protect the nurse from exposure to blood or body fluids and are standard practice for all parenteral procedures.
E. A 5/8 inch needle is designed for subcutaneous injections and is too short to reach the muscle layer in an adult, especially in clients with higher body weight. Using a needle of this length for an IM injection would risk depositing the medication in subcutaneous tissue rather than the muscle, which could impair absorption and effectiveness and potentially cause local irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging intake of high potassium foods is contraindicated. Anuric clients cannot excrete potassium effectively, which puts them at risk for hyperkalemia, a potentially life-threatening condition that can cause cardiac arrhythmias or cardiac arrest. Dietary potassium must be restricted, and blood potassium levels closely monitored, particularly in the days between dialysis sessions.
B. Initiating a toileting schedule is unnecessary for an anuric client. Since the client does not produce urine, interventions related to bladder management, such as scheduled voiding, are irrelevant. Nursing care should focus on other physiological and systemic needs.
C. Monitoring for signs of anemia is a priority. CKD leads to reduced production of erythropoietin by the kidneys, which decreases red blood cell production. Signs of anemia include fatigue, pallor, shortness of breath, tachycardia, and decreased activity tolerance. Early identification allows timely interventions such as erythropoiesis-stimulating agents (ESAs), iron supplementation, or blood transfusions. Anemia also affects quality of life and overall functional status in long-term care residents.
D. Providing perineal skin barrier cream is generally for clients who are incontinent. While maintaining skin integrity is important, this intervention is not a priority for an anuric client with no urine output. Resources and interventions should focus on more relevant complications of CKD, such as anemia, electrolyte imbalances, and cardiovascular issues.
Correct Answer is A
Explanation
A. Laboratory results have returned to normal levels indicate that the client’s physiological status has improved and the health problem is resolving. This is a direct measure of improved health outcomes and demonstrates that the interventions were effective in achieving the intended goal.
B. Client satisfaction reflects the quality of care from the client’s perspective but does not necessarily indicate improvement in the client’s health status. A client may be satisfied with care even if health outcomes are not optimal.
C. Ensuring that nursing diagnoses are consistent with the client’s needs reflects accurate assessment and planning but does not confirm that health outcomes have been achieved. It demonstrates proper process rather than actual improvement in health.
D. Delivering interventions safely and on time ensures quality and safety of care, but it measures process adherence, not whether the client’s health has improved. A client could receive all interventions correctly and still not achieve the desired health outcomes.
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