The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?
Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus.
Rotate injections between the abdomen and gluteal areas.
Expel the air in the prefilled syringe prior to Injection.
Massage the injection site to increase absorption.
The Correct Answer is A
A. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus:
This instruction is accurate and appropriate for the administration of low molecular weight heparin subcutaneously. Injecting into the abdominal area at least 2 inches (5.1 cm) away from the umbilicus is a commonly recommended site for subcutaneous injections due to the availability of subcutaneous tissue and the reduced risk of injury to underlying structures.
B. Rotate injections between the abdomen and gluteal areas:
While rotation of injection sites is important to prevent tissue damage and lipodystrophy, for subcutaneous injections of low molecular weight heparin, the abdomen is typically the preferred site due to better absorption and reduced risk of complications. Therefore, rotating between the abdomen and gluteal areas may not be necessary or recommended for this specific medication.
C. Expel the air in the prefilled syringe prior to injection:
Expelling air from the prefilled syringe is a standard practice to ensure accurate dosing and prevent air embolism, but it is not specific to the administration of low molecular weight heparin. This instruction should be included in general injection technique education but is not specific to the administration of this medication.
D. Massage the injection site to increase absorption:
Massaging the injection site after administration of low molecular weight heparin is not recommended, as it can increase the risk of bleeding or hematoma formation at the injection site. Massaging the site is generally contraindicated for anticoagulant injections to avoid disrupting the clotting process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Turn the head to the right and left:
Turning the head involves rotation of the cervical spine, which primarily consists of pivot joints rather than hinge joints. This action is more relevant to the movement of pivot joints.
B. Extend the arm at the side and rotate in circles:
Extending the arm and rotating it in circles primarily involves the movement of ball-and-socket joints, such as the shoulder joint, rather than hinge joints.
C. Bend the arm by flexing the ulna to the humerus:
This action involves bending the arm at the elbow joint by flexing the ulna (forearm bone) towards the humerus (upper arm bone). The elbow joint is a hinge joint, allowing primarily flexion and extension movements.
D. Tilt the pelvis forwards and backwards:
Tilting the pelvis forwards and backwards primarily involves the movement of ball-and-socket joints in the hip area, rather than hinge joints.
Correct Answer is B
Explanation
A. Observe the client's body language:
This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.
B. Ask the client for learning feedback:
This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.
C. Provide client-focused information:
This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.
D. Reinforce key points with the client:
This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.
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