A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
Check the medication administration record to verify the client's allergies.
Slowly inject the medication into the site without aspirating.
Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
Ensure an air bubble is present in the prefilled enoxaparin syringe.
The Correct Answer is B, E, A, D, C
B. Check the medication administration record to verify the client's allergies. Before preparing or administering any medication, the nurse must verify the client’s medication order and allergies to ensure safety. E. Ensure an air bubble is present in the prefilled enoxaparin syringe. The prefilled syringe contains an air bubble that should remain to ensure the entire dose is administered and to prevent medication from tracking back through the tissue. A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. Enoxaparin should be administered in the subcutaneous tissue of the abdomen, avoiding areas near the umbilicus to reduce the risk of irritation and bruising. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. Pinching the skin ensures the medication is delivered into the subcutaneous tissue, and injecting at a 90° angle minimizes pain and ensures proper technique. C. Slowly inject the medication into the site without aspirating. Aspiration is not necessary for subcutaneous injections. Slowly injecting reduces discomfort and ensures proper absorption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin sealant before applying the ostomy bag helps protect the skin around the stoma, creating a barrier against irritation and potential leaks from the stool. It demonstrates the client's understanding of preventive measures to maintain skin integrity.
Choice B Reason:
"I will use moisturizing soap to clean around the stoma before applying the bag." This statement is inappropriate. While keeping the area around the stoma clean is important, using moisturizing soap might not be recommended as it can leave residue and interfere with the adhesive properties of the bag. Typically, mild soap and water are recommended for cleansing.
Choice C Reason:
"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result in an excessively large opening, potentially leading to leaks or irritation. The ideal size is generally recommended to be as close to the stoma size as possible without causing pressure on the stoma.
Choice D Reason:
"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular emptying of the ostomy bag is necessary, the frequency can vary based on individual needs and stoma output. Some individuals might need to empty it more frequently or less often, depending on their stool output and comfort level.
Correct Answer is A
Explanation
Choice A Reason:
Older adults are at increased risk for falls due to decreased vision, balance issues, and decreased reaction time. Placing white or brightly colored tape on the edges of stairs enhances visibility, reducing the risk of missteps and falls.
Choice B Reason:
Placing area rugs on wooden floors is not appropriate. Area rugs on wooden floors can pose a tripping hazard, especially for older adults who might have mobility issues. They can easily slip or trip on loose rugs. Securing rugs with non-slip backing or removing them entirely is a better safety measure.
Choice C Reason:
Running wires and cords under carpeting is not appropriate. Running wires and cords under carpeting can create tripping hazards and increase the risk of electrical issues, including potential overheating and fire hazards. It's safer to secure cords along walls or use cord covers to prevent tripping and reduce potential electrical hazards
Choice D Reason:
Heating systems should be inspected annually to prevent carbon monoxide poisoning and fire hazards. An annual inspection is recommended, especially for older adults who may have impaired smell or cognition, making them less likely to detect gas leaks or heating malfunctions.
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