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:

The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.

Choice B reason:

The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.

Choice C reason:

The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.

Choice D reason:

The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?

Correct Answer is C

Explanation

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Correct Answer is D

Explanation

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