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 C

Explanation

A. "My appetite is increased." Diphenhydramine is an antihistamine that primarily treats allergic reactions by blocking histamine receptors. While antihistamines can sometimes cause increased appetite as a side effect, this is not an indicator of effectiveness in treating an allergic reaction.

B. "I don't have a headache anymore." While diphenhydramine may help with headaches due to its sedative and antihistamine effects, headache relief is not the primary goal when treating an allergic reaction. The effectiveness of diphenhydramine in this scenario should be assessed based on improvements in allergic symptoms rather than headache relief.

C. "My voice is no longer hoarse." Hoarseness can be a sign of airway involvement due to allergic reaction-related swelling (laryngeal edema). Diphenhydramine reduces histamine-induced inflammation, which can help resolve airway symptoms. Improvement in hoarseness suggests reduced swelling and a lower risk of airway obstruction, making this the best indicator of effectiveness.

D. "I am feeling more alert." Diphenhydramine commonly causes drowsiness due to its sedative effects. Feeling more alert would be an unusual response to the medication and does not indicate improvement in the allergic reaction. The primary concern is symptom resolution, particularly respiratory symptoms, rather than changes in alertness.

A. Alprazolam B. Rotavirus vaccine C. Niacin D. Hepatitis A vaccine

Correct Answer is D

Explanation

A. Alprazolam. Alprazolam, a benzodiazepine, is metabolized in the liver and can accumulate in clients with chronic liver disease, increasing the risk of sedation, confusion, and hepatic encephalopathy. Benzodiazepines should be used cautiously or avoided in clients with liver impairment.

B. Rotavirus vaccine. The rotavirus vaccine is a live, attenuated vaccine given to infants to prevent severe diarrhea caused by rotavirus infection. It is not recommended for adults, including those with chronic liver disease, as it is not indicated for their age group or condition.

C. Niacin. Niacin is used to lower cholesterol and treat vitamin B3 deficiency, but it can cause hepatotoxicity, especially in high doses. In clients with chronic liver disease, niacin may worsen liver function, making it an inappropriate choice unless absolutely necessary and closely monitored.

D. Hepatitis A vaccine. Clients with chronic liver disease are at higher risk of severe complications from hepatitis A infection. Vaccination provides protection against hepatitis A, which can cause acute liver failure in individuals with pre-existing liver disease. It is recommended to prevent further liver damage and protect overall health.

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