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

Administer the medication into the client's muscle.

Apply firm pressure to the injection site following administration.

Insert the syringe needle halfway into the client's skin.

Expel the air bubble from the syringe prior to injection

Answer and Explanation

The Correct Answer is D

A. Administer the medication into the client's muscles.
Explanation: This is incorrect because enoxaparin is usually administered subcutaneously, not into the muscle.
B. Apply firm pressure to the injection site following administration.
Explanation: This is incorrect because while applying gentle pressure after a subcutaneous injection is common practice, it is not specific to enoxaparin.
C. Insert the syringe needle halfway into the client's skin.
Explanation: This is incorrect because the needle should be inserted fully into the subcutaneous tissue, not just halfway, for proper administration of enoxaparin.
D. Expel the air bubble from the syringe prior to injection.
Explanation: This is the correct action. Expelling air bubbles from the syringe prior to injection helps ensure accurate dosing and prevents air from being injected into the subcutaneous tissue.
When administering enoxaparin (low molecular weight heparin) subcutaneously, it's important to expel any air bubbles from the syringe before injection. Air bubbles can cause discomfort and inaccuracies in dosage. The nurse should gently tap the syringe to move air bubbles to the top and then push the plunger slightly to expel the air. The other options are not correct procedures for administering enoxaparin. It is typically injected into the subcutaneous tissue, not a muscle, and firm pressure is not typically applied after administration. The needle is fully inserted into the skin, not halfway.

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Correct Answer is A

Explanation

A. Pruritus, which is itching, is a common adverse effect associated with the use of opioids, including morphine. Itching can occur when opioids are administered through various routes, including epidural infusion. The exact mechanism for opioid-induced itching is not fully understood, but it is thought to be related to the release of histamines or other chemical mediators.
B. Gastric bleeding is not a common adverse effect of epidurally administered opioids like morphine. Gastric bleeding is more associated with non-steroidal anti-inflammatory drugs (NSAIDs) and certain other medications.
C & D. Tachypnea (rapid breathing) and cough are not typical adverse effects of epidurally administered opioids. However, opioids can cause respiratory depression (slow and shallow breathing), so monitoring respiratory status is important when using these medications.

A. Another formulation of potassium should be given IV. B. Potassium chloride should be diluted in dextrose 5% in water. C. The client should be treated by giving potassium by IV bolus. D. The potassium infusion rate is too rapid.

Correct Answer is D

Explanation

A. Another formulation of potassium should be given IV: The type of potassium formulation isn't the issue in this scenario.

B. Potassium chloride should be diluted in dextrose 5% in water: While potassium chloride can be administered in different solutions, the primary concern here is the infusion rate, not the specific diluent.

C. The client should be treated by giving potassium by IV bolus: The concern here is the rate of administration, not the route. Potassium is commonly administered through an IV infusion rather than a bolus due to the risk of cardiac arrhythmias associated with rapid administration.

D. A nurse is caring for a client who is to receive potassium replacement. The nurse should clarify the prescription with the provider because the potassium infusion rate is too rapid.

The prescription indicates that the client should receive potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 minutes. This rate of administration is too fast for potassium replacement and could lead to potentially serious complications, such as hyperkalemia or cardiac arrhythmias. The typical recommended rate for potassium replacement is 10-20 mEq/hour, and this prescription exceeds that range.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is receiving morphine via continuous epidural infusion. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is A

Explanation

A nurse is caring for a client who is to receive potassium replacement. The provider's prescription reads, "Potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 min." For which of the following reasons should the nurse clarify this prescription with the provider?

Correct Answer is D

Explanation

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