a nurse is planning to administer an im injection into a clients deltoid muscle which of the following actions should the nurse take

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. When administering an IM injection into a client's deltoid muscle, which of the following actions should the nurse take?

A. Use a 21-gauge needle for the injection
B. Inject the medication at a 90-degree angle
C. Inject the medication 12.7 cm (5 in) below the acromion process
D. Inject the medication 2.54 cm (1 in) below the acromion process

Correct answer: B

Rationale: The correct answer is to inject the medication at a 90-degree angle when administering an IM injection into the deltoid muscle. This angle ensures proper delivery of the medication into the muscle tissue. Choice A is incorrect because the gauge of the needle for a deltoid IM injection is usually smaller, around 23-25 gauge. Choices C and D are incorrect as the injection site for the deltoid muscle is approximately 2.54 cm (1 in) below the acromion process, not 12.7 cm (5 in).

2. What is the most appropriate action for a healthcare provider to take when a patient refuses a prescribed medication?

A. Document the refusal and notify the healthcare provider.
B. Administer the medication at a later time.
C. Explain the importance of the medication and its effects.
D. Respect the patient's right to refuse the medication.

Correct answer: D

Rationale: The correct answer is to respect the patient's right to refuse the medication. It is crucial to uphold the patient's autonomy and decision-making capacity when it comes to their treatment. Administering the medication later without the patient's consent (Choice B) disregards their autonomy and can lead to ethical issues. Documenting the refusal and notifying the healthcare provider (Choice A) is important for legal and continuity of care purposes but should come after respecting the patient's decision. While explaining the importance of the medication (Choice C) is valuable for promoting understanding and compliance, the immediate concern should be respecting the patient's refusal.

3. How can dehydration be assessed in an elderly patient?

A. Checking skin turgor on the forearm
B. Assessing for dry mucous membranes
C. Checking for orthostatic hypotension
D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

4. A nurse is providing discharge teaching to a client following a myocardial infarction (MI). Which of the following activities should the client avoid?

A. Swimming in a pool
B. Driving a car
C. Light housework
D. Walking on flat ground

Correct answer: B

Rationale: The correct answer is B: Driving a car. Driving a car can be physically and emotionally taxing, increasing the risk of complications soon after a myocardial infarction. It requires quick reflexes and decision-making abilities, which may be impaired during the recovery period. Swimming in a pool, light housework, and walking on flat ground are generally safe and beneficial activities for clients following a myocardial infarction as they promote circulation, muscle strength, and overall well-being.

5. Which of the following is a common manifestation of opioid withdrawal?

A. Bradycardia and hypotension
B. Tremors and increased blood pressure
C. Severe muscle weakness and fatigue
D. Severe hallucinations and delusions

Correct answer: B

Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.