The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?
The nurse aspirates immediately prior to injecting the medication.
The nurse gently massages the injection site immediately afterward.
The nurse draws up the medication into a 1-mL syringe with a 32-gauge needle.
The nurse injects the medication into the soft tissue of the patient’s abdomen.
The Correct Answer is D
Choice A rationale:
Aspirating prior to injecting enoxaparin is not recommended.
Aspiration was once a common practice to check if a needle had entered a blood vessel.
However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation.
Additionally, aspirating can increase the risk of needlestick injuries.
For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.
Choice B rationale:
Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation.
It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding.
The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.
Choice C rationale:
The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections.
This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.
Choice D rationale:
The abdomen is the preferred site for subcutaneous injections of enoxaparin.
The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication.
The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks.
However, the abdomen is generally the preferred site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Incorrect. Mixing insulin detemir and insulin aspart in the same syringe is generally not recommended due to the following reasons:
Altered Pharmacokinetics: Mixing insulins can potentially alter their absorption and action profiles, leading to unpredictable blood glucose control.
Stability Concerns: The compatibility of different insulins in a mixed solution is not always guaranteed, potentially leading to precipitation or decreased potency.
Dosing Accuracy: Drawing up mixed insulins accurately can be challenging, especially when different dosages are required for each type.
Manufacturer Recommendations: Insulin manufacturers typically advise against mixing different insulins unless specifically instructed by a healthcare professional.
Choice B rationale:
Incorrect. While the order of drawing up insulins may have a minor impact on mixing, it does not address the fundamental concerns of mixing different insulins in the same syringe. The primary issue is the potential for altered pharmacokinetics, stability concerns, and dosing accuracy, as explained in the rationale for Choice A.
Choice D rationale:
Incorrect. Rolling insulin bottles between the palms is a technique used to gently resuspend insulin particles that may have settled at the bottom. However, it does not pertain to the correct procedure for drawing up different insulins for administration.
Choice C rationale:
Correct. Administering insulin detemir and insulin aspart using separate syringes and different injection sites is the most appropriate approach for several reasons:
Maintains Pharmacokinetics: It ensures that each insulin maintains its intended absorption and action profile, promoting optimal blood glucose control.
Ensures Stability: Using separate syringes eliminates the risk of potential incompatibility issues that could arise from mixing insulins.
Promotes Dosing Accuracy: Drawing up insulins in separate syringes allows for greater precision in administering the correct dosage of each type.
Aligns with Manufacturer Guidelines: This approach adheres to the recommendations of insulin manufacturers, ensuring safe and effective administration.
Additional Considerations:
Nurses should always consult the latest insulin administration guidelines and individual patient needs for optimal care.
Proper education and counseling should be provided to patients who require multiple insulin injections to ensure adherence and understanding of correct administration techniques.
Correct Answer is A
Explanation
Choice A rationale:
Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle.
Key features of Stage 2 pressure injuries that align with the patient's presentation:
Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1.
Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries.
Rationales for other choices:
Choice B: Stage 4
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.
Choice C: Stage 3
Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.
Choice D: Stage 1
Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.
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