A nurse is evaluating a return demonstration of enoxaparin administration by a client. Which of the following client actions indicates an understanding of the teaching?

Administers the injection in the abdomen

Massages the site to enhance absorption

Releases the skin fold before injecting the medication

Aspirates the medication after injection

Answer and Explanation

The Correct Answer is A

A. Administers the injection in the abdomen: Enoxaparin should be injected subcutaneously into the abdomen at least 2 inches away from the umbilicus. The abdominal area provides consistent absorption and reduces the risk of bruising or tissue injury.

B. Massages the site to enhance absorption: The site should not be massaged after injection, as this can cause bruising, tissue irritation, and increased bleeding due to the anticoagulant effect of enoxaparin.

C. Releases the skin fold before injecting the medication: The skin fold should be maintained throughout the injection to ensure that the medication is delivered into the subcutaneous tissue, not the muscle.

D. Aspirates the medication after injection: Aspiration should be avoided because it can cause tissue trauma and bruising. Enoxaparin should be administered smoothly without pulling back on the plunger.

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Correct Answer is D

Explanation

A. Medication reconciliation report: A medication reconciliation report is used to compare the client’s current medications with new prescriptions to prevent errors during transitions of care. It is not used to document incidents or near misses.

B. Root cause analysis form: A root cause analysis is a detailed process performed after a serious adverse event to determine underlying system issues. It is not the initial documentation tool for a single medication error or near-miss.

C. Plan of care: The plan of care outlines nursing interventions and goals for the client’s treatment. It is not used to record or report medication-related incidents.

D. Occurrence report: An occurrence (incident) report is the appropriate document for recording medication errors or near misses, such as discovering an allergy before administration. It provides information for quality improvement and risk management without becoming part of the client’s medical record.

A. 1+ deep tendon reflexes B. Pupils equal, round, react to light, accommodation C. Blood pressure 122/88 mm Hg D. 24 hr urine output 960 mL

Correct Answer is A

Explanation

A. 1+ deep tendon reflexes: Decreased deep tendon reflexes indicate magnesium toxicity, as excessive magnesium depresses neuromuscular activity. This finding suggests the serum magnesium level may be too high and requires immediate reporting to prevent respiratory or cardiac complications.

B. Pupils equal, round, react to light, accommodation: Normal pupillary response does not indicate magnesium toxicity. This finding shows intact neurological function and does not require intervention.

C. Blood pressure 122/88 mm Hg: This blood pressure is within acceptable range for a client receiving magnesium sulfate for preeclampsia. It suggests that the medication is helping control hypertension without causing hypotension.

D. 24 hr urine output 960 mL: This urine output is adequate (greater than 30 mL/hr average) and indicates proper renal function. Since magnesium is excreted through the kidneys, normal urine output helps prevent accumulation and toxicity.

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A nurse is evaluating a return demonstration of enoxaparin administration by a client. Which of the following client actions indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

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