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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Aplastic anemia results in an increased rate of RBC destruction

Aplastic anemia does not result from an increased rate of red blood cell (RBC) destruction. Instead, it is characterized by the bone marrow’s inability to produce sufficient new blood cells, including RBCs, white blood cells, and platelets. This condition leads to pancytopenia, a deficiency of all types of blood cells.

Choice B reason: Aplastic anemia is associated with a decreased intake of iron

Aplastic anemia is not typically associated with a decreased intake of iron. Iron deficiency anemia is a different condition where the body lacks enough iron to produce hemoglobin. Aplastic anemia, on the other hand, is due to the failure of the bone marrow to produce adequate blood cells.

Choice C reason: Aplastic anemia results from decreased bone marrow production of RBCs

This statement is correct. Aplastic anemia occurs when the bone marrow fails to produce enough new blood cells. This can be due to various factors, including autoimmune disorders, exposure to toxic chemicals, certain medications, and viral infections. The decreased production of RBCs, along with other blood cells, leads to the symptoms associated with aplastic anemia.

Choice D reason: Aplastic anemia results in an inability to absorb vitamin B12

Aplastic anemia is not related to the absorption of vitamin B12. Pernicious anemia is the condition associated with an inability to absorb vitamin B12 due to a lack of intrinsic factor. Aplastic anemia is specifically related to the bone marrow’s failure to produce sufficient blood cells.

A. Have you had a recent influenza infection? B. Have you traveled overseas recently? C. Do you have a history of chronic alcohol abuse? D. Are you taking a multivitamin?

Correct Answer is A

Explanation

Choice A reason: Have you had a recent influenza infection?

Guillain-Barré syndrome (GBS) is often preceded by an infection, most commonly respiratory or gastrointestinal infections. Influenza is a significant respiratory infection that can trigger GBS. Asking about recent influenza infection helps in identifying a potential cause of the syndrome. According to the Mayo Clinic, many cases of GBS occur after a respiratory or gastrointestinal infection1. Therefore, this question is crucial in the assessment of a client with suspected GBS.

Choice B reason: Have you traveled overseas recently?

While travel history can be relevant in diagnosing various conditions, it is less directly related to Guillain-Barré syndrome. GBS is not typically associated with travel but rather with infections that can occur anywhere. Therefore, this question is less pertinent compared to asking about recent infections.

Choice C reason: Do you have a history of chronic alcohol abuse?

Chronic alcohol abuse can lead to various neurological conditions, but it is not specifically linked to Guillain-Barré syndrome. GBS is an acute condition often triggered by an infection, not by chronic alcohol use. Thus, while this question might be relevant in a broader neurological assessment, it is not directly related to GBS.

Choice D reason: Are you taking a multivitamin?

The use of multivitamins is generally not related to the development of Guillain-Barré syndrome. This question does not help in identifying the cause or confirming the diagnosis of GBS. It is more relevant to a general health assessment rather than a specific inquiry for GBS.

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

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