A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?

Insert the needle at a 45° or 90° angle.

Hold the skin taut during administration

Massage the injection site after administrating the enoxaparin.

Use a 4 cm (1.6in) needle

Answer and Explanation

The Correct Answer is A

A. Insert the needle at a 45° or 90° angle. Enoxaparin is administered subcutaneously, and subcutaneous injections should be given at either a 45° or 90° angle, depending on the client’s body size and the amount of subcutaneous tissue available. A 90° angle is typically used for clients with more subcutaneous tissue, while a 45° angle is appropriate for those with less.

B. Hold the skin taut during administration. When giving subcutaneous injections, the skin should be gently pinched rather than held taut. Pinching helps ensure the medication is delivered into the fatty tissue rather than the muscle, reducing the risk of intramuscular injection, which can increase bleeding risk with anticoagulants like enoxaparin.

C. Massage the injection site after administering the enoxaparin. Massaging the injection site is contraindicated because it can cause tissue irritation, bruising, and increased risk of bleeding. Instead, gentle pressure may be applied with a gauze pad if necessary to minimize bleeding.

D. Use a 4 cm (1.6 in) needle. A needle length of 4 cm (1.6 inches) is too long for a subcutaneous injection and increases the risk of intramuscular administration, which could lead to increased bleeding and bruising. The recommended needle length for subcutaneous injections is typically ½ inch (1.25 cm) to ⅝ inch (1.6 cm) to ensure proper medication delivery.

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Correct Answer is B

Explanation

A. Assist the client to a left lateral position. The preferred position for vaginal suppository insertion is the dorsal recumbent (lying on the back with knees bent) or the lithotomy position. The left lateral position is typically used for rectal suppository administration, not vaginal medication insertion.

B. Insert the suppository along the posterior wall of the vaginal canal. The suppository should be inserted along the posterior vaginal wall, as this allows for proper absorption and helps ensure the medication remains in place. The client should be advised to lie down for at least 10-15 minutes after insertion to prevent the suppository from slipping out.

C. Apply a light coating of petroleum jelly to the suppository. Petroleum jelly should never be used as it can interfere with medication absorption and may break down the suppository. If lubrication is needed, a small amount of water-soluble lubricant (e.g., KY Jelly) can be applied to facilitate insertion.

D. Put on sterile gloves before handling the suppository. Clean gloves (not sterile gloves) are sufficient for vaginal suppository administration. The vaginal canal is not a sterile environment, so strict aseptic technique is not required. However, proper hand hygiene and glove use are essential to prevent contamination and infection.

A. Drowsiness B. Dyskinesia C. Musculoskeletal pain D. Weight gain

Correct Answer is C

Explanation

A. Drowsiness. Alendronate, a bisphosphonate used to treat osteoporosis, does not cause drowsiness. It primarily affects bone metabolism rather than the central nervous system. If a client experiences drowsiness, it is likely due to another cause rather than the medication itself.

B. Dyskinesia. Dyskinesia refers to involuntary movements often associated with neurological disorders or medications affecting dopamine, such as antipsychotics or Parkinson’s medications. Alendronate does not affect dopamine or the nervous system, making dyskinesia an unlikely adverse effect.

C. Musculoskeletal pain. A known side effect of alendronate is musculoskeletal pain, including bone, joint, and muscle discomfort. This occurs due to the medication’s effects on bone remodeling and turnover. While mild pain may resolve on its own, persistent or severe pain should be reported to the provider as it may require dose adjustment or discontinuation.

D. Weight gain. Alendronate does not cause weight gain. It primarily acts on bone tissue to inhibit osteoclast-mediated bone resorption, preventing further bone loss. Clients experiencing unexplained weight gain should be evaluated for other potential causes, such as metabolic conditions or lifestyle factors.

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A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?

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