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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
The provider should be informed of this change as soon as possible to prevent further complications.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.
While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.
While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.
While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
Correct Answer is ["0.4"]
Explanation
To calculate the amount of heparin to administer, use the formula:
mL of heparin=units available units ordered×1mL available
Substituting the values given in the question, we get:
mL of heparin=100004000×11=0.4
Therefore, the nurse should administer 0.4 mL of heparin.
Normal ranges for heparin therapy vary depending on the condition being treated and the laboratory method used to measure APTT.
A general range is 60 to 80 seconds or 1.5 to 2.5 times the control value.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.