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. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:
This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.
B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:
This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.
C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:
This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.
D. Before changing assignments, determine which staff members have fitted particulate filter masks:
While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.
Correct Answer is D
Explanation
A. Clamping the urinary catheter prior to the collection:
This step involves temporarily stopping the flow of urine through the catheter. Whether gloves are needed for this step depends on the specific protocol and the potential risk of exposure to bodily fluids. If there's a possibility of urine leakage or splashing during the clamping process, gloves may be necessary to protect against contact with the urine.
B. Recording the output on the flowsheet in the client's room:
This step involves documenting the urine output on a flowsheet or chart. It typically does not require direct contact with bodily fluids, as the nurse is handling paperwork rather than the urine itself. Therefore, gloves are usually not necessary for this task.
C. Transporting the urine specimen to the laboratory:
Once the urine specimen has been collected and properly sealed in a biohazard bag, the nurse transports it to the laboratory for analysis. As long as the specimen is securely packaged, there is no need for gloves during transportation unless there is a risk of spillage or leakage. However, if there is a possibility of contact with bodily fluids due to leakage, gloves should be worn to protect against exposure.
D. Using the syringe to remove the specimen from the catheter:
This step involves using a sterile syringe to withdraw the urine from the catheter for collection. Since it involves direct contact with bodily fluids (i.e., urine), gloves are necessary to protect against potential exposure to pathogens. Wearing gloves during this step helps maintain proper infection control practices and minimizes the risk of contamination.
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