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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The statement “Please do not raise your voice at the children. I am the one who left the dishes in the sink.” is an example of effective communication. It demonstrates taking responsibility for one’s actions and addressing the issue calmly and directly. This approach helps to de-escalate potential conflict and promotes a respectful and constructive dialogue among family members. Effective communication in family therapy involves clear, honest, and respectful exchanges that foster understanding and resolution of issues.
Choice B reason:
The statement “If you keep saying that, I will tell everyone what you did last night.” is an example of ineffective communication. It is threatening and manipulative, which can escalate conflict and create a hostile environment. Such statements undermine trust and respect among family members, making it difficult to resolve issues constructively. Effective communication should avoid threats and focus on expressing feelings and concerns in a non-confrontational manner.
Choice C reason:
The statement “Can you tell me the reason you get upset each time I go to the mall?” is a step towards effective communication as it seeks to understand the other person’s feelings. However, it could be improved by using “I” statements to express personal feelings and concerns. For example, “I feel concerned when you get upset each time I go to the mall. Can we talk about it?” This approach reduces defensiveness and encourages open dialogue.
Choice D reason:
The statement “She is always bossing me around. Should she do that?” is an example of ineffective communication. It is accusatory and does not address the issue constructively. Effective communication should focus on specific behaviors and how they affect the individual, rather than making general accusations. For example, “I feel frustrated when I am told what to do. Can we discuss how we can share responsibilities more fairly?” This approach promotes understanding and cooperation.
Correct Answer is A
Explanation
Choice A reason:
Offering the child a choice of taking the medication with juice or water is an effective strategy. Giving children choices helps them feel a sense of control and can reduce resistance. This approach respects the child’s autonomy and can make the medication-taking process less stressful for both the child and the nurse.
Choice B reason:
Telling the child it is candy is not an appropriate strategy. This can lead to mistrust and confusion, as the child may expect candy and be disappointed or upset when they realize it is medication. It is important to be honest with children about what they are taking to build trust and ensure they understand the importance of the medication.
Choice C reason:
Telling the child he will have to have a shot instead is not a helpful approach. This can create fear and anxiety about both the medication and future medical procedures. Using threats or scare tactics can damage the child’s trust in healthcare providers and make them more resistant to treatment in the future.
Choice D reason:
Hiding the medication in a large dish of ice cream is not recommended. While it might seem like an easy way to get the child to take the medication, it can lead to issues with dosage accuracy and the child may develop an aversion to the food used to hide the medication. It is better to use transparent and honest methods to encourage cooperation.
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