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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because waiting for notification that the system has been rebooted can delay the client's care and compromise safety. The nurse should report the problem as soon as possible and use alternative methods of documentation.
Choice B Reason: This is incorrect because identifying information as late entry in the record is a secondary action that should be done after the system is restored. The nurse should prioritize resolving the technical issue and ensuring continuity of care.
Choice C Reason: This is correct because notifying information services department of the situation is the first action that the nurse should take to alert the experts who can troubleshoot and fix the problem. The nurse should also follow the facility's policy and procedure for documenting in a downtime situation.
Choice D Reason: This is incorrect because printing electronic medical record (EMR) from backup server may not be feasible or accessible depending on the extent of the system failure. The nurse should use paper forms or charts as a temporary measure until the system is back online.
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