A nurse is preparing to administer enoxaparin to a client.
Which of the following actions should the nurse take?
Expel the air bubble from the syringe prior to injection.
Apply firm pressure to the injection site following administration.
Insert the syringe needle halfway into the client’s skin.
Administer the medication into the client’s muscles.
The Correct Answer is A
Choice A is the correct action. Enoxaparin is a low molecular weight heparin that is administered subcutaneously. Expelling the air bubble helps ensure accurate dosing and prevents the injection of air into the subcutaneous tissue.
Choice B is wrong because firm pressure should not be applied to the injection site following administration. This can cause bruising or bleeding at the site. Instead, a dry gauze pad can be used to cover the site if needed.
Choice C is wrong because the syringe needle should not be inserted halfway into the client’s skin. The full length of the needle should be inserted at a 90° angle into a fold of skin that has been cleansed with an alcohol swab.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:
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Inject air into the NPH (intermediate-acting) insulin vial: Insert the needle into the NPH vial and inject an amount of air equal to the intended NPH insulin dose.
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Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.
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Withdraw the NPH insulin from the vial: Without removing the needle from the NPH vial, withdraw the NPH insulin dose from the vial.
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Withdraw the regular insulin from the vial: Without removing the needle from the regular insulin vial, withdraw the regular insulin dose from the vial.
This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.
Correct Answer is C
Explanation
This is a high level of potassium in the blood (the normal range is 3.5 to 5 mEq/L) and can be dangerous for the heart.
Triamterene is a potassium-sparing diuretic that prevents the body from losing too much potassium in the urine. It can cause hyperkalemia (high potassium), especially in people with kidney disease, diabetes, or severe illness. The nurse should check the potassium level before giving triamterene and hold the medication if it is above 5 mEq/L.
The other choices are incorrect because:
Choice A: Sodium 142 mEq/L.
This is a normal level of sodium in the blood (the normal range is 135 to 145 mEq/L) and does not require withholding triamterene. Triamterene can cause hyponatremia (low sodium) by increasing the excretion of sodium in the urine. The nurse should monitor the sodium level during triamterene therapy and report any signs of low sodium such as confusion, weakness, or seizures.
Choice B: BUN 16 mg/dL.
This is a normal level of blood urea nitrogen (BUN) in the blood (normal range is 7 to 20 mg/dL) and does not require withholding
triamterene. BUN is a measure of kidney function and can be elevated in kidney disease or dehydration. Triamterene can cause an increase in BUN by reducing the blood flow to the kidneys or by interacting with other medications that affect the kidneys. The nurse should monitor the BUN level during triamterene therapy and report any signs of kidney impairment such as decreased urine output, swelling, or nausea. •
Choice D: Albumin 4 g/dL.
This is a normal level of albumin in the blood (the normal range is 3.4 to 5.4 g/dL) and does not require withholding triamterene. Albumin is a protein that helps maintain fluid balance and transport substances in the blood. Triamterene does not affect albumin levels directly, but it can cause fluid loss or retention that may alter albumin levels indirectly. The nurse should monitor the albumin level during triamterene therapy and report any signs of fluid imbalance such as weight changes, edema, or shortness of breath.
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