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 C
Explanation
Choice A Reason:
"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.
Choice B Reason:
"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.
While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.
Choice C Reason:
"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.
Choice D Reason:
"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.
Correct Answer is A
Explanation
A. Elevate the head of the client's bed for 1 hr after the feeding:Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.
B. Administer the feeding solution at a cold temperature: Feeding solutions should be administered at room temperature to prevent gastrointestinal discomfort or cramping.
C. Rotate the jejunostomy tube once per day:
Rotation of the jejunostomy tube is not a standard practice. Jejunostomy tubes are typically secured in place, and rotation is not necessary.
D. Flush the tube with 90mL of sterile water before and after the feeding:
Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.
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