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:
Side effect: A side effect is an effect of a drug that is secondary to the main intended effect. It is usually predictable and may be either beneficial or harmful. However, constipation is not a common or expected side effect of iron supplements. It is more likely to be an adverse reaction.
Choice B rationale:
Therapeutic effect: The therapeutic effect is the intended effect of a drug, the one that is desired to treat the condition. In this case, the therapeutic effect of the iron supplement would be to increase the patient's iron levels. Constipation is not the desired effect of the iron supplement, so it is not a therapeutic effect.
Choice C rationale:
Adverse reaction: An adverse reaction is an unwanted or harmful reaction to a drug that is not necessarily predictable. It can range from mild to severe. Constipation is a common adverse reaction to iron supplements. It is thought to be caused by the iron binding to undigested food in the intestines, making it harder to pass stool.
Choice D rationale:
Toxicity: Toxicity refers to a poisonous or harmful effect of a drug. It is usually caused by taking too much of a drug or by a drug interacting with another drug or substance. Constipation is not a sign of iron toxicity. Iron toxicity can cause symptoms such as nausea, vomiting, abdominal pain, and diarrhea.
Correct Answer is C
Explanation
Choice A rationale:
Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.
Choice B rationale:
Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.
Choice D rationale:
Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.
Choice C rationale:
Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.
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