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 {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

NSAID use. The client has been taking ibuprofen (an NSAID) twice daily while also receiving prednisone (a corticosteroid) for asthma exacerbation. Both NSAIDs and corticosteroids inhibit prostaglandin production, which normally protects the stomach lining. This combination increases the risk of gastric irritation, peptic ulcers, and gastrointestinal bleeding.
Recent immunization. The client received the influenza vaccine three days ago, but this does not significantly increase the risk of infection. The flu shot contains inactivated or weakened virus, meaning it cannot cause the flu. The client’s asthma may increase their risk of complications from the flu, but the vaccine helps reduce this risk rather than increasing it.
Weight gain. The client has gained 1.36 kg (3 lb) in one week, which is likely due to fluid retention from prednisone use. While long-term corticosteroid use can lead to Cushing syndrome, this condition develops over weeks to months of high-dose steroid therapy, not within a short period. Therefore, the client is at a higher risk of peptic ulcers rather than Cushing syndrome.
Cushing syndrome. Cushing syndrome results from chronic corticosteroid use leading to fat redistribution, muscle weakness, skin thinning, and hyperglycemia. However, this client is on a short-term tapering dose of prednisone, making Cushing syndrome unlikely at this stage.
Influenza. Although the client has asthma, which increases the risk of complications from respiratory infections, there is no indication that they have developed the flu. The flu shot helps prevent infection, and there are no reports of fever, body aches, or respiratory symptoms suggestive of influenza.
Peptic ulcers. The combination of NSAIDs and corticosteroids significantly increases the risk of peptic ulcer disease by weakening the stomach lining and promoting acid production. The client should be advised to monitor for signs of gastric irritation, such as abdominal pain, black stools, or nausea, and may require a proton pump inhibitor (PPI) like omeprazole for ulcer prevention.

A. Tingling sensation B. Hypertension C. Dizziness D. Flushing

Correct Answer is B

Explanation

A. Tingling sensation. A mild tingling or paresthesia is a common side effect of sumatriptan due to its vasoconstrictive action. While it should be monitored, it is not typically harmful and does not require immediate medical intervention.

B. Hypertension. Sumatriptan works by constricting blood vessels to relieve migraine symptoms, but it can also cause a dangerous increase in blood pressure. Severe hypertension can lead to complications such as stroke or myocardial infarction. This is the priority finding that requires immediate reporting to prevent life-threatening cardiovascular events.

C. Dizziness. Dizziness can occur due to sumatriptan’s vasoconstrictive properties or from the migraine itself. While it can be uncomfortable, it is not an immediate threat to the client’s safety unless it is severe or associated with other neurological symptoms.

D. Flushing. Facial flushing is a known side effect of sumatriptan and is generally harmless. It occurs due to transient vasodilation in the skin and does not indicate a serious adverse reaction. Monitoring is appropriate, but it does not require urgent intervention.

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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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Naxlex Comprehensive Predictor Exams

A nurse in a primary care clinic is caring for a client. Complete the following sentence by using the lists of options. The client is most at risk for developing ....... due to their ...........

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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Correct Answer is B

Explanation

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