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 B
Explanation
Choice A reason: Discussing the visitation policy is important for the client’s overall hospital experience but does not directly relate to the prevention of postoperative complications. Visitation policies help manage the flow of visitors and ensure the client gets adequate rest, but they do not address specific postoperative risks.
Choice B reason: Instructing the client about the use of a sequential compression device is crucial for preventing deep vein thrombosis (DVT) and pulmonary embolism, which are common postoperative complications. Sequential compression devices (SCDs) help improve blood circulation in the legs, reducing the risk of blood clots forming during periods of immobility after surgery.
Choice C reason: Teaching the client how to use the PCA pump (patient-controlled analgesia) is important for pain management but does not directly prevent postoperative complications. Proper pain management can aid in recovery by allowing the client to move and breathe more effectively, but it is not a primary preventive measure for complications like DVT or infections.
Choice D reason: Reviewing the pain scale helps the client communicate their pain levels effectively, which is important for managing postoperative pain. However, like the PCA pump, it does not directly prevent complications. Effective pain management can contribute to overall recovery but is not a standalone preventive measure.
Correct Answer is B
Explanation
Choice A reason: 90 bpm is the threshold below which the nurse should withhold digoxin for a 6-month-old infant. Digoxin can slow the heart rate, and administering it when the heart rate is already low can increase the risk of bradycardia, a serious heart rhythm disturbance.
Choice B reason: 100 bpm is above the threshold for withholding digoxin in a 6-month-old infant. While it is important to monitor the heart rate, digoxin can be safely administered if the apical heart rate is above 90 bpm.
Choice C reason: 110 bpm is also above the threshold for withholding digoxin. This heart rate indicates that the infant’s heart rate is within a safe range for administering the medication.
Choice D reason: 120 bpm is well above the threshold for withholding digoxin. This heart rate is considered safe for administering the medication, as it indicates the heart rate is not too low.
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