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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Hypovolemia B. Poorly controlled blood glucose levels C. Protein deficiency D. Adequate hydration E. Routine ambulation F. Steroid therapy G. Obesity H. Vitamin C supplementation

Correct Answer is ["A","B","C","F","G"]

Explanation

Rationale for each choice:

Choice A: Hypovolemia

Impaired perfusion: Hypovolemia, or a decrease in circulating blood volume, leads to reduced blood flow to the wound site. This means that less oxygen and nutrients are delivered to the tissues, which are essential for healing processes like cell growth and collagen synthesis.

Impaired oxygen delivery: Oxygen is crucial for white blood cells to fight infection and for fibroblasts to create new tissue. Hypovolemia can significantly hinder wound healing by reducing oxygen availability at the wound site.

Delayed inflammatory response: The inflammatory phase of wound healing relies on adequate blood flow to deliver immune cells and initiate tissue repair. Hypovolemia can delay this response, leading to prolonged inflammation and delayed healing.

Decreased fibroblast activity: Fibroblasts, the cells responsible for collagen production, require oxygen and nutrients to function effectively. Hypovolemia can impair fibroblast activity, leading to reduced collagen synthesis and delayed wound closure.

Choice B: Poorly controlled blood glucose levels

Impaired immune function: High blood glucose levels impair the function of white blood cells, making the body more susceptible to infections. Infections at the wound site can significantly delay healing.

Impaired collagen synthesis: Hyperglycemia can also impair collagen synthesis, which is essential for wound strength and closure.

Vascular damage: Chronically high blood glucose levels can damage blood vessels, leading to impaired blood flow and oxygen delivery to the wound site, further hindering healing.

Choice C: Protein deficiency

Impaired collagen synthesis: Protein is a crucial building block for collagen, the main structural protein in connective tissue. A lack of protein can lead to reduced collagen production, resulting in delayed wound healing and weaker scar tissue.

Impaired immune function: Protein is also essential for immune cell function. A deficiency can impair the body's ability to fight infections, increasing the risk of wound complications.

Choice D: Adequate hydration

Incorrect: Staying well-hydrated supports the body’s healing process by ensuring proper blood flow and nutrient transport, thus it does not impede wound healing.

Choice E: Routine ambulation

Incorrect: Early ambulation after surgery promotes healing by improving circulation and reducing the risk of complications like blood clots, making it beneficial rather than harmful.

Choice F: Steroid therapy

Immunosuppressive effects: Steroids suppress the immune system, making the body less able to fight infections and hindering the inflammatory phase of wound healing.

Decreased collagen synthesis: Steroids can also decrease collagen synthesis, leading to weaker wound tissue and delayed closure.

Choice G: Obesity

Impaired blood flow: Excess adipose tissue can compress blood vessels, reducing blood flow to the wound site and impairing oxygen and nutrient delivery.

Increased inflammation: Adipose tissue produces inflammatory cytokines, which can prolong the inflammatory phase of wound healing and delay tissue repair.

Higher risk of infection: The folds of skin in obese individuals can create moist environments that are more prone to bacterial growth and infection.

Choice H: Vitamin C supplementation

Incorrect: Vitamin C plays a key role in collagen formation and tissue repair, so it supports rather than hinders wound healing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is preparing to administer 40 mg of enoxaparin subcutaneously to a patient. Which of the following techniques should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

Correct Answer is ["B","C","E"]

Explanation

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

Correct Answer is ["A","B","C","F","G"]

Explanation

For the Nursing Exam #3 (Winter 2023), which of the following is an example of allopathic treatment?

The patient has a large red, blistered area on the left hip.Which pressure injury stage will be recorded in the patient’s chart?

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Which patient would most likely benefit from a sitz bath?

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.Which term will the nurse use to describe this area?

A patient has an order for a subcutaneous injection of insulin.Into which of the following tissues will the nurse prepare to give this injection?

The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient’s last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department?