A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?
"Administer this medication into your leg muscle.".
"Expel the excess air in the syringe before you administer the medication.".
"Insert the entire needle into your skin to administer medication completely.".
"Take ibuprofen for fever following administration of this medication.".
The Correct Answer is C
Answer: C. "Insert the entire needle into your skin to administer medication completely."
Rationale:
A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.
B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.
C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.
D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.
Choice B rationale:
Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.
Choice C rationale:
Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.
Choice D rationale:
This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.
Correct Answer is A
Explanation
Dispose of the client's feces and urine in a special container.
Choice A rationale:
This is the correct choice. Brachytherapy involves the placement of a radiation source in or near the tumor. To minimize radiation exposure to others, the client's bodily fluids (feces and urine) should be considered radioactive and disposed of properly in a designated container.
Choice B rationale:
While limiting the time of visitors can be a good measure to reduce radiation exposure, it is not the priority intervention. The primary concern is proper handling and disposal of radioactive bodily fluids.
Choice C rationale:
Keeping the client's linens in the room until after removal of the radiation source is not the correct choice. Radioactive linens should be handled and laundered separately, following appropriate safety protocols.
Choice D rationale:
Providing one dosimeter badge for staff to share while caring for the client is not adequate. Each staff member involved in direct care should have their dosimeter badge to monitor their individual radiation exposure levels.
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