A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?

Insert the needle at a 45° or 90° angle.

Hold the skin taut during administration

Massage the injection site after administrating the enoxaparin.

Use a 4 cm (1.6in) needle

Answer and Explanation

The Correct Answer is A

A. Insert the needle at a 45° or 90° angle. Enoxaparin is administered subcutaneously, and subcutaneous injections should be given at either a 45° or 90° angle, depending on the client’s body size and the amount of subcutaneous tissue available. A 90° angle is typically used for clients with more subcutaneous tissue, while a 45° angle is appropriate for those with less.

B. Hold the skin taut during administration. When giving subcutaneous injections, the skin should be gently pinched rather than held taut. Pinching helps ensure the medication is delivered into the fatty tissue rather than the muscle, reducing the risk of intramuscular injection, which can increase bleeding risk with anticoagulants like enoxaparin.

C. Massage the injection site after administering the enoxaparin. Massaging the injection site is contraindicated because it can cause tissue irritation, bruising, and increased risk of bleeding. Instead, gentle pressure may be applied with a gauze pad if necessary to minimize bleeding.

D. Use a 4 cm (1.6 in) needle. A needle length of 4 cm (1.6 inches) is too long for a subcutaneous injection and increases the risk of intramuscular administration, which could lead to increased bleeding and bruising. The recommended needle length for subcutaneous injections is typically ½ inch (1.25 cm) to ⅝ inch (1.6 cm) to ensure proper medication delivery.

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Correct Answer is B

Explanation

A. Jaundice. Jaundice, or yellowing of the skin and eyes, is a sign of liver dysfunction and may indicate hepatotoxicity rather than an allergic reaction. Some medications can cause drug-induced liver injury (DILI), but jaundice is not a typical symptom of an immediate hypersensitivity reaction.

B. Urticaria. Urticaria (hives) is a classic allergic reaction that appears as raised, red, itchy welts on the skin. It occurs due to the release of histamine in response to an allergen, which increases capillary permeability and leads to swelling and itching. Urticaria may be accompanied by angioedema, respiratory distress, or anaphylaxis, requiring immediate intervention if severe.

C. Bradycardia. Bradycardia (slow heart rate) is not a typical manifestation of an allergic reaction. While anaphylaxis can cause hypotension and tachycardia due to systemic vasodilation, bradycardia is more commonly associated with beta-blockers, heart block, or vagal stimulation rather than an allergic response.

D. Hypertension. Allergic reactions, especially severe ones like anaphylaxis, typically cause vasodilation and hypotension, not hypertension. While stress or anxiety related to an allergic episode may lead to a temporary rise in blood pressure, persistent hypertension is not a direct sign of an allergic reaction.

A. Breastfeeding B. Client allergy C. Gentamycin prescription D. Hematocrit E. Hemoglobin

Correct Answer is ["B","C"]

Explanation

A. Breastfeeding. Ceftriaxone is generally considered safe during breastfeeding because only a small amount is excreted in breast milk. While monitoring for gastrointestinal disturbances or thrush in the infant is advised, breastfeeding is not a contraindication for ceftriaxone use.

B. Client allergy. The client has a penicillin allergy, which raises concerns about cross-reactivity with cephalosporins, including ceftriaxone. Although the cross-reactivity rate is low, clients with a history of severe allergic reactions (e.g., anaphylaxis, angioedema, or urticaria) to penicillin should avoid cephalosporins. The nurse should clarify the nature of the penicillin allergy before administering ceftriaxone.

C. Gentamycin prescription. Ceftriaxone and gentamicin are both nephrotoxic, and using them together increases the risk of kidney damage. The client should be monitored for renal function impairment, and alternative antibiotic therapy may be considered if necessary. The nurse should discuss this potential drug interaction with the provider before administration.

D. Hematocrit. The client’s hematocrit (32%) is low but does not require withholding ceftriaxone. A slightly decreased hematocrit is expected postpartum, especially in cases of infection or recent delivery. Ceftriaxone is not known to cause significant hematologic suppression that would make this a contraindication.

E. Hemoglobin. The client’s hemoglobin (9 g/dL) is lower than normal, likely due to postpartum blood loss or infection-related inflammation. However, ceftriaxone does not directly affect hemoglobin levels, so this is not a reason to withhold the medication.

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Body System	Findings
Vital Signs/General History	Temperature 36.4° C (97.6° F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74mm Hg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client varicose veins.
Cardiovascular/ Respiratory	S1 S2 auscultated. No murmurs. All peripheral pulses 2+ Lung sounds clear bilaterally
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odourless. Last menstrual period was 3 months ago
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities

A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is scheduled to receive a dose of ceftriaxone The nurse has reviewed the client's electronic medical record (EMR). Which of the following findings should the nurse recommend withholding the ceftriaxone? Select all that apply.

Correct Answer is ["B","C"]

Explanation

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