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 nurse should plan to take the following action:

A) Mix the medications with a semisolid food for the client.

Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.

Options B, C, and D are not recommended for a client with dysphagia:

B) Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.

C) Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.

D) Tilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.

A. Weight loss. B. Confusion. C. Bruxism. D. Insomnia.

Correct Answer is B

Explanation

a.While weight changes can be concerning, they are not typically life-threatening and can occur as a common side effect of antidepressants, including citalopram. Monitoring is important, but it does not require immediate reporting.

b.This is the priority to report because confusion can indicate a serious reaction to the medication, such as serotonin syndrome, especially if it occurs in conjunction with other symptoms like agitation, hallucinations, or rapid heart rate. Confusion can also signal worsening mental status, which is critical for someone with major depression.

c.This refers to teeth grinding, which can occur with certain antidepressants. While it should be monitored and possibly addressed with interventions, it is generally not an immediate concern compared to confusion.

d.Sleep disturbances can be a side effect of citalopram and may need adjustment of treatment or recommendations for sleep hygiene, but they are not as urgent as confusion.

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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 planning to administer medications to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who has major depression and a new prescription for citalopram. Which of the following adverse effects is the priority for the nurse to report to the provider?

Correct Answer is B

Explanation

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