The nurse is preparing to administer 40 mg of enoxaparin subcutaneously to a patient. Which of the following techniques should the nurse use?
The nurse should aspirate immediately prior to injecting the medication.
The nurse should gently massage the injection site immediately afterward.
The nurse should draw up the medication into a 1-mL syringe with a 32-gauge needle.
The nurse should inject the medication into the soft tissue of the patient’s abdomen.
The Correct Answer is D
Choice A rationale:
Aspiration prior to injection of enoxaparin is not recommended. Key reasons for this contraindication include:
Absence of Large Blood Vessels in Subcutaneous Tissue: Enoxaparin is administered subcutaneously, targeting the fatty tissue layer beneath the skin. This tissue generally lacks large blood vessels, significantly reducing the risk of accidental intravascular injection. Aspiration, traditionally intended to prevent such occurrences, becomes unnecessary in this context.
Potential for Hematoma Formation: The act of aspiration itself can create a vacuum within the subcutaneous tissue, leading to trauma and bleeding at the injection site. This can result in hematoma formation, causing discomfort and potential interference with medication absorption.
No Evidence of Benefit: Research studies have not demonstrated any clear advantages of aspiration when administering subcutaneous enoxaparin injections. In fact, some studies have suggested a potential increase in bruising and bleeding associated with aspiration.
Manufacturer Guidelines: Enoxaparin manufacturers explicitly advise against aspiration in their product instructions, aligning with current evidence-based practices.
Choice B rationale:
Massaging the injection site after administering enoxaparin is also not recommended.
Rationale for this contraindication:
Accelerated Absorption: Massaging can increase local blood flow, potentially accelerating the absorption of enoxaparin. This could lead to higher-than-intended drug levels in the bloodstream, increasing the risk of bleeding complications.
Discomfort and Hematoma Risk: Similar to aspiration, massage can create mechanical stress on the injection site, potentially causing bruising, discomfort, or hematoma formation.
Choice C rationale:
While a 1-mL syringe with a 32-gauge needle is a suitable option for subcutaneous injections, it's not the only correct choice. Considerations for syringe and needle selection:
Needle Length: The needle should be short enough to ensure subcutaneous administration, typically ranging from 5/8 to 1 inch in length.
Syringe Size: The syringe size should accommodate the volume of medication being administered, providing clear visibility of the dose.
Patient Comfort: Smaller-gauge needles (like 32-gauge) are often preferred for subcutaneous injections as they tend to cause less discomfort. However, other factors, such as medication viscosity and patient preferences, may influence needle selection.
Choice D rationale:
The abdomen is the preferred injection site for enoxaparin due to several reasons:
Abundant Subcutaneous Tissue: The abdomen generally has a thicker layer of subcutaneous tissue, providing ample space for medication absorption and reducing the risk of intramuscular injection.
Ease of Access: The abdomen is often easily accessible for self-injection or administration by a caregiver, promoting patient comfort and convenience.
Reduced Pain: Subcutaneous injections in the abdomen are typically less painful compared to other potential sites like the arms or thighs.
Additional considerations for enoxaparin administration:
Rotate Injection Sites: To prevent tissue damage and promote consistent absorption, it's crucial to rotate injection sites within the recommended areas (abdomen, thighs, upper buttocks).
Monitor for Adverse Effects: Observe for any signs of bleeding, bruising, or allergic reactions following enoxaparin administration.
Adhere to Storage Guidelines: Store enoxaparin at room temperature and protect it from light to ensure its efficacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Incorrect. Patients who develop tolerance to a medication do not typically maintain a stable dose over time. Instead, they often require increasing doses to achieve the same effect.
Physiological adaptation: The body adapts to the presence of the medication, leading to a decreased response over time. This adaptation can occur at various levels, including receptor downregulation, changes in enzyme activity, or alterations in neurotransmitter release.
Individual variability: The rate and extent of tolerance development vary significantly among individuals, influenced by factors such as genetics, age, overall health, and medication type.
Choice B rationale:
Incorrect. Impaired liver or kidney function can affect drug metabolism and elimination, but this is not the primary mechanism of tolerance.
Metabolic impairment: Liver or kidney dysfunction can lead to drug accumulation in the body, potentially increasing the risk of side effects or toxicity. However, this does not necessarily cause tolerance, which is a specific phenomenon of decreased responsiveness to the medication's effects.
Choice C rationale:
Correct. This statement accurately describes the hallmark characteristic of tolerance.
Dose escalation: As tolerance develops, patients often require higher doses of the medication to achieve the same therapeutic effect. This can lead to a cycle of increasing doses and potential risks of adverse effects.
Clinical implications: Tolerance is a significant consideration in medication management, as it can affect treatment efficacy, adherence, and the risk of side effects.
Choice D rationale:
Incorrect. Tolerance can develop even when patients adhere strictly to their prescribed medication regimen. It is a physiological phenomenon that is not solely dependent on patient behavior.
Adherence vs. tolerance: While non-adherence can contribute to treatment failure, it is not the underlying cause of tolerance.
Correct Answer is ["B","C","E"]
Explanation
Choice B rationale:
Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.
Choice C rationale:
Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.
Choice E rationale:
Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.
Rationale for incorrect choices:
Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.
Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.
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