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

Aspirate for a blood return before depressing the plunger.

Insert the needle at a 45-degree angle.

The nurse should not expel the air bubble in the prefilled syringe.

Administer the medication 2.54 cm (1 inch) from the umbilicus.

Answer and Explanation

The Correct Answer is C

Choice A reason: Aspirating for a blood return before depressing the plunger is not recommended when administering enoxaparin. Enoxaparin is given subcutaneously, and aspiration is not necessary for subcutaneous injections. Aspiration can cause tissue damage and increase the risk of bleeding.

Choice B reason: Inserting the needle at a 45-degree angle is appropriate for subcutaneous injections if the patient has limited subcutaneous tissue. However, for enoxaparin, the preferred angle is 90 degrees to ensure the medication is delivered into the subcutaneous tissue.

Choice C reason: Not expelling the air bubble in the prefilled syringe is correct. The air bubble in the prefilled syringe of enoxaparin is designed to ensure the entire dose is administered and to prevent leakage of the medication. Expelling the air bubble can result in an incomplete dose.

Choice D reason: Administering the medication 2.54 cm (1 inch) from the umbilicus is correct for subcutaneous injections in the abdomen. However, this statement alone does not address the specific consideration of the air bubble in the prefilled syringe, which is crucial for enoxaparin administration.

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Correct Answer is C

Explanation

Choice A reason:

Oxygen saturation of 95% is within the normal range (typically 95-100%) and indicates adequate oxygenation. However, it does not specifically indicate that the lung has re-expanded. Oxygen saturation can be influenced by various factors, including supplemental oxygen and overall respiratory function.

Choice B reason:

Occasional bubbling in the water seal chamber can indicate air leakage from the pleural space, which suggests that the lung has not fully re-expanded. Continuous or intermittent bubbling usually signifies that air is still escaping from the lung into the pleural space.

Choice C reason:

No fluctuations in the water seal chamber, also known as “tidaling,” is a key indicator that the lung has re-expanded. When the lung is fully expanded, the pleural space is eliminated, and there is no longer a pressure difference to cause fluctuations in the water seal chamber. This finding suggests that the lung is now in contact with the chest wall and functioning normally.

Choice D reason:

No reports of pleuritic chest pain can indicate that the client is experiencing less discomfort, but it is not a definitive sign that the lung has re-expanded. Pain levels can vary based on individual pain tolerance and the effectiveness of pain management strategies.

A. Bright yellow B. Bright red C. Dark amber D. Pale pink

Correct Answer is D

Explanation

Choice A reason: Bright yellow

Bright yellow urine is typically a sign of normal hydration and is not expected after a transurethral prostatectomy. This color does not indicate the presence of blood or other substances that might be expected following surgery.

Choice B reason: Bright red

Bright red urine indicates significant bleeding, which is not typical after the initial postoperative period. While some blood in the urine is expected immediately after surgery, bright red urine should be reported to a healthcare provider as it may indicate a complication.

Choice C reason: Dark amber

Dark amber urine is usually a sign of dehydration or the presence of bilirubin. It is not typically associated with the expected postoperative changes following a transurethral prostatectomy. This color does not reflect the expected mild bleeding that can occur after the procedure.

Choice D reason: Pale pink

Pale pink urine is expected following a transurethral prostatectomy due to the presence of small amounts of blood in the urine. This is a normal finding as the surgical site heals. The pale pink color indicates mild bleeding, which is common and usually resolves as the healing process continues.

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

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