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 B
Choice A rationale:
The nurse should not instruct the client to administer enoxaparin to the leg muscle. Enoxaparin is a low molecular weight heparin that should be administered subcutaneously, typically in the abdomen or thigh, but not into the muscle.
Choice B rationale:
This is the correct choice because before administering enoxaparin, the nurse should instruct the client to expel the excess air from the syringe. Leaving air bubbles in the syringe can result in incorrect dosing and potential harm to the client.
Choice C rationale:
The nurse should not advise the client to insert the entire needle into the skin to administer the medication. Enoxaparin is given subcutaneously, which means the needle should only be inserted into the subcutaneous tissue, not entirely through the skin.
Choice D rationale:
The nurse should not tell the client to take ibuprofen for fever following the administration of enoxaparin. Enoxaparin is an anticoagulant used to prevent blood clots and is not related to fever management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.
Choice B rationale:
Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.
Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.
Choice C rationale:
This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.
Choice D rationale:
Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.
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