A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse plan to take?
Aspirate for a blood return before depressing the plunger.
Insert the needle at a 45-degree angle.
The nurse should not expel the air bubble in the prefilled syringe.
Administer the medication 2.54 cm (1 inch) from the umbilicus.
The Correct Answer is C
Choice A reason: Aspirating for a blood return before depressing the plunger is not recommended when administering enoxaparin. Enoxaparin is given subcutaneously, and aspiration is not necessary for subcutaneous injections. Aspiration can cause tissue damage and increase the risk of bleeding.
Choice B reason: Inserting the needle at a 45-degree angle is appropriate for subcutaneous injections if the patient has limited subcutaneous tissue. However, for enoxaparin, the preferred angle is 90 degrees to ensure the medication is delivered into the subcutaneous tissue.
Choice C reason: Not expelling the air bubble in the prefilled syringe is correct. The air bubble in the prefilled syringe of enoxaparin is designed to ensure the entire dose is administered and to prevent leakage of the medication. Expelling the air bubble can result in an incomplete dose.
Choice D reason: Administering the medication 2.54 cm (1 inch) from the umbilicus is correct for subcutaneous injections in the abdomen. However, this statement alone does not address the specific consideration of the air bubble in the prefilled syringe, which is crucial for enoxaparin administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Washing the cord daily with mild soap and water is not recommended. The best practice is to keep the umbilical cord stump clean and dry. Cleaning it with water and mild soap can be done if it gets dirty, but it should not be a daily routine as it might delay the drying process.
Choice B reason:
Applying petroleum jelly to the cord stump is not advised. The goal is to keep the stump dry to promote natural drying and falling off. Petroleum jelly can keep the area moist, which is counterproductive to the drying process.
Choice C reason:
Covering the cord with the diaper is not recommended. Instead, the diaper should be folded down below the umbilical cord stump to keep it exposed to air and prevent irritation from urine or stool3. This helps the stump to dry out and fall off naturally.
Choice D reason:
Giving a sponge bath until the cord stump falls off is the correct instruction. Submerging the baby in water can delay the drying and falling off of the stump. Sponge baths help keep the area dry and clean, promoting faster healing.
Correct Answer is D
Explanation
Choice A reason: Bright yellow
Bright yellow urine is typically a sign of normal hydration and is not expected after a transurethral prostatectomy. This color does not indicate the presence of blood or other substances that might be expected following surgery.
Choice B reason: Bright red
Bright red urine indicates significant bleeding, which is not typical after the initial postoperative period. While some blood in the urine is expected immediately after surgery, bright red urine should be reported to a healthcare provider as it may indicate a complication.
Choice C reason: Dark amber
Dark amber urine is usually a sign of dehydration or the presence of bilirubin. It is not typically associated with the expected postoperative changes following a transurethral prostatectomy. This color does not reflect the expected mild bleeding that can occur after the procedure.
Choice D reason: Pale pink
Pale pink urine is expected following a transurethral prostatectomy due to the presence of small amounts of blood in the urine. This is a normal finding as the surgical site heals. The pale pink color indicates mild bleeding, which is common and usually resolves as the healing process continues.
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