The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Massage the injection site to increase absorption.

Rotate injections between the abdomen and gluteal areas.

Expel the air in the prefilled syringe prior to injection.

Inject in abdominal area at least 2 inches from the umbilicus.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Massaging the injection site can cause bruising and bleeding, and is not recommended for subcutaneous heparin injections.

Choice B Reason: Rotating injections between different body sites can increase the risk of hematoma formation and skin irritation, and is not advised for subcutaneous heparin injections.

Choice C Reason: Expelling the air in the prefilled syringe can result in a loss of medication dose, and is not necessary for subcutaneous heparin injections.

Choice D Reason: Injecting in the abdominal area at least 2 inches from the umbilicus is the correct technique for subcutaneous heparin injections, as it reduces the risk of injury to blood vessels and nerves, and ensures consistent absorption of the medication.

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Correct Answer is A

Explanation

Choice A: Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications.
Choice B: Tell the client the medication needs more time to work is not a correct intervention because it may dismiss the client’s pain and delay appropriate treatment. The nurse should acknowledge the client’s pain and explain the expected onset and duration of the medication.
Choice C: Ask the UAP to offer a backrub to the client is not a correct intervention because it may not be sufficient or appropriate for the client’s pain. The nurse should assess the client’s pain before delegating any nonpharmacological interventions to the UAP.
Choice D: Encourage the client to focus on taking deep breaths is not a correct intervention because it may not be effective or feasible for the client’s pain. The nurse should assess the client’s pain and offer other complementary therapies that are suitable and acceptable for the client.

A. Regular exercise. B. Stress reduction. C. Smoking cessation. D. Low-fat diet.

Correct Answer is C

Explanation

Choice A: Regular exercise is a good lifestyle modification, but it is not as important as smoking cessation. Exercise can help lower blood pressure, cholesterol, and weight, but it cannot reverse the damage caused by smoking.

Choice B: Stress reduction is a good lifestyle modification, but it is not as important as smoking cessation. Stress can trigger or worsen cardiac problems, but it cannot cause them as directly as smoking.

Choice C: Smoking cessation is the most important lifestyle modification because smoking is a major risk factor for cardiac disease. Smoking damages the blood vessels, increases blood pressure, reduces oxygen supply, and promotes clot formation.

Choice D: Low-fat diet is a good lifestyle modification, but it is not as important as smoking cessation. A low-fat diet can help lower cholesterol and prevent plaque buildup, but it cannot undo the effects of smoking.

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