A nurse is preparing to administer subcutaneous enoxaparin.
In which order should the nurse perform the following steps?
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Locate the injection site 5 cm (2 in) to the right or left of the umbilicus.
Slowly inject the medication into the site without aspirating.
Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle.
Check the medication administration record to verify the client's allergies.
Ensure an air bubble is present in the prefilled enoxaparin syringe.
The Correct Answer is D,A,E,C,B
Choice D rationale
Checking the medication administration record to verify the client's allergies ensures patient safety by preventing allergic reactions to enoxaparin. Allergies to medications can cause adverse reactions, which can be life-threatening. This step confirms that enoxaparin is safe for administration to the client.
Choice A rationale
Locating the injection site 5 cm (2 in) to the right or left of the umbilicus ensures that the injection is given in the appropriate subcutaneous tissue. This site has fewer blood vessels and nerves, reducing the risk of injury and ensuring proper absorption of the medication.
Choice E rationale
Ensuring an air bubble is present in the prefilled enoxaparin syringe helps to lock the medication into the subcutaneous tissue and prevents the medication from leaking out. The air bubble technique is specific to enoxaparin administration.
Choice C rationale
Pinching clean skin at the injection site and darting the needle into the skinfold at a 90° angle ensures that the medication is administered into the subcutaneous tissue. This technique minimizes pain and ensures that the medication is delivered correctly.
Choice B rationale
Slowly injecting the medication into the site without aspirating prevents tissue damage and ensures that the medication is delivered into the subcutaneous tissue. Aspirating is not required for subcutaneous injections and can cause unnecessary pain and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lying down after a meal can increase the risk of acid reflux by allowing stomach contents to move back into the esophagus. Clients with GERD are advised to remain upright for at least 30 minutes after eating.
Choice B rationale
Sleeping flat on the back can exacerbate GERD symptoms by allowing stomach acid to flow back into the esophagus more easily. Elevating the head of the bed or using pillows to raise the upper body can help reduce reflux.
Choice C rationale
Eating six small meals each day can help prevent overloading the stomach, reducing the risk of acid reflux. Smaller, more frequent meals are recommended for managing GERD.
Choice D rationale
Orange juice is acidic and can irritate the esophagus, worsening GERD symptoms. Clients with GERD are typically advised to avoid citrus fruits and juices.
Correct Answer is C
Explanation
Choice A rationale
The supine position with the head of the bed flat does not facilitate the safe and effective draining of fluid from the pleural cavity. This position can compromise the respiratory status of the patient and is therefore not suitable for a thoracentesis.
Choice B rationale
The Trendelenburg position, where the head is lower than the feet, can increase intracranial pressure and is not suitable for thoracentesis. This position does not allow for the optimal access to the pleural space needed for the procedure.
Choice C rationale
Sitting upright while leaning forward over pillows is the ideal position for a thoracentesis. This position allows the fluid to accumulate at the base of the pleural cavity and provides easy access for the procedure. It also facilitates better breathing and reduces the risk of injury to the diaphragm and other internal structures.
Choice D rationale
Lying prone with arms extended away from the body does not provide adequate access to the pleural space for thoracentesis. This position also makes it difficult to manage and monitor the patient's respiratory status during the procedure. .
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