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A nurse is preparing to administer enoxaparin to a client.
Which of the following actions should the nurse take?

A.

Expel the air bubble from the syringe prior to injection.

B.

Apply firm pressure to the injection site following administration.

C.

Insert the syringe needle halfway into the client’s skin.

D.

Administer the medication into the client’s muscles.

Answer and Explanation

The Correct Answer is B

 

Choice A rationale:

The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.

 

Choice B rationale:

After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.

 

Choice C rationale:

The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.

 

Choice D rationale:

Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.


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Related Questions

Correct Answer is C

Explanation

Clozapine is an antipsychotic medication that is used to treat schizophrenia and other psychotic disorders. It works by affecting the balance of certain chemicals in the brain.

Choice A is wrong because clozapine can cause weight gain, not weight loss, in some people. This can increase the risk of diabetes, high cholesterol, and heart problems. The nurse should advise the client to monitor their weight regularly and to follow a healthy diet and exercise plan.

Choice B is wrong because ringing in the ears (tinnitus) is not an expected adverse effect of clozapine. However, clozapine can cause other ear problems, such as otitis media (middle ear infection) or otitis externa (outer ear infection). The nurse should instruct the client to report any ear pain, discharge, or hearing loss to their provider.

Choice D is wrong because diarrhoea is not a common adverse effect of clozapine. However, clozapine can cause constipation, which can be severe and lead to bowel obstruction or perforation. The nurse should advise the client to drink plenty of fluids, eat high-fibre foods, and use laxatives as prescribed by their provider.

Choice C is correct because fever is a serious adverse effect of clozapine that may indicate a life-threatening condition called

agranulocytosis. Agranulocytosis is a severe reduction in white blood cells that can impair the immune system and increase the risk of infections. The nurse should instruct the client to notify their provider immediately if they develop a fever or any signs of infection, such as sore throat, cough, or flu-like symptoms. The client should also have regular blood tests to monitor their white blood cell count while taking clozapine.

Correct Answer is D

Explanation

The most appropriate action for the nurse to take in this situation is:

d. Apply a warm, moist compress.

Here's why the other options are not recommended:

  • a. Initiate a new IV distal to the initial site:This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
  • b. Slow the IV solution rate:Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
  • c. Maintain the extremity below the level of the heart:This action would actually worsen the edema by promoting fluid accumulation at the site.

Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:

  • Stop the IV infusion.
  • Assess the extent of the infiltration or extravasation.
  • Document the findings.
  • Elevate the affected extremity.
  • Consult with a physician for further instructions and potential treatment.

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