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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should instruct the client to avoid drinking beverages while sucking on a nicotine lozenge because this can interfere with the absorption of nicotine and reduce its effectiveness. Some possible explanations for the other choices are:
Choice B is wrong because chewing nicotine gum for 10 minutes before spitting it out is too short.
The recommended duration is at least 30 minutes to allow enough nicotine to be released and absorbed through the lining of the mouth.
Choice C is wrong because changing the nicotine patch every other day is not frequent enough.
The patch should be changed daily and applied to a different skin site to prevent irritation and ensure a steady dose of nicotine.
Choice D is wrong because administering 2 sprays of nicotine nasal spray in each nostril with each dose is too much.
The recommended dose is one spray per nostril, up to five times per hour or 40 times per day.
Using too much nasal spray can cause side effects such as nasal irritation, sneezing, coughing, headache, or nausea.
Correct Answer is C
Explanation
Nitroglycerin transdermal patches are used to prevent episodes of angina (chest pain) in people who have coronary artery disease (narrowing of the blood vessels that supply blood to the heart). They work by relaxing the blood vessels so that the heart does not need to work as hard and therefore does not need as much oxygen.
Choice A is wrong because nitroglycerin transdermal patches cannot be used to treat an attack of angina once it has begun. They can only be used to prevent attacks of angina. If you have chest pain, you should use another form of nitroglycerin, such as sublingual tablets or spray.
Choice B is wrong because headache is a common side effect of nitroglycerin transdermal patches and does not mean that you should stop using them. However, you should tell your doctor if the headaches are severe or do not go away. You may also take acetaminophen to relieve the headache.
Choice D is wrong because you do not need to cover the patch with dry gauze when taking a shower. You may shower while you are wearing a nitroglycerin skin patch. If a patch loosens or falls off, replace it with a fresh one.
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