A nurse is preparing to administer enoxaparin to a client.
Which of the following actions should the nurse take?

Expel the air bubble from the syringe prior to injection.

Apply firm pressure to the injection site following administration.

Insert the syringe needle halfway into the client’s skin.

Administer the medication into the client’s muscles.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.

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Correct Answer is A

Explanation

The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.

Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.

It is suitable for children aged 8 to 17 years who can read and understand words.

Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.

Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.

It is suitable for infants aged 0 to 6 months who cannot communicate verbally.

A. Apply pressure to the IV site. B. Elevate the extremity. C. Slow the infusion rate. D. Flush the IV catheter.

Correct Answer is B

Explanation

This will help reduce swelling and discomfort caused by the infiltration of fluid into the tissues. Elevating the extremity also promotes venous return and prevents further fluid accumulation.

Choice A is wrong because applying pressure to the IV site can increase the risk of tissue damage and infection.

Pressure can also obstruct blood flow and cause thrombophlebitis.

Choice C is wrong because slowing the infusion rate will not stop the infiltration of fluid into the tissues.

Slowing the infusion rate can also delay the delivery of medication or fluid to the client.

Choice D is wrong because flushing the IV catheter can worsen the infiltration of fluid into the tissues.

Flushing the IV catheter can also introduce air or bacteria into the bloodstream and cause complications.

Normal ranges for peripheral IV infusion are dependent on the type and volume of fluid, the size and location of the catheter, and the condition of the client. Generally, peripheral IV infusion rates should not exceed 100 mL/hr for adults and 60 mL/hr for children.

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A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissues surrounding the insertion site. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse is caring for a client who develops an anaphylactic reaction to IV antibiotic administration. After assessing the client’s respiratory status and stopping the medication infusion, which of the following actions should the nurse take next?

A nurse is preparing to administer enoxaparin to a client.
Which of the following actions should the nurse take?