A nurse observes a newly licensed nurse administer enoxaparin subcutaneously using a pre- filled syringe. Which of the following indicates appropriate medication administration?
Transferring the medication into a U-100 insulin syringe for injection
Removing the air bubble from the prefilled syringe prior to administration
Inserting the needle into the tissue using a 30-degree angle
Administering the injection in the love handles. 2 in from the umbilicus
The Correct Answer is D
D. Administering the injection in the love handles, 2 inches from the umbilicus. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
A. Enoxaparin should not be transferred into another syringe unless specifically instructed by the manufacturer or pharmacy guidelines. Pre-filled syringes are designed to deliver the correct dose accurately and safely.
B. It is important not to remove the air bubble from the prefilled syringe, as it is designed to ensure the entire dose of medication is administered.
C. A 30-degree angle is too shallow for subcutaneous injections and may result in the medication being deposited too close to the skin surface, potentially causing irritation or affecting absorption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.
B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.
C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.
D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.
Correct Answer is B
Explanation
B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.
A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.
C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.
D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.
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