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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Hand hygiene is critical for preventing the spread of MRSA. Washing hands removes any bacteria that may have been picked up during contact with the infected client or surfaces in the room. Proper handwashing technique includes using soap and water or an alcohol-based hand sanitizer for at least 20 seconds.

Choice B rationale

Reusing unsoiled gloves is not recommended because MRSA can persist on surfaces and gloves for prolonged periods. Changing gloves each time entering the room ensures any contamination is not transferred to different areas or patients.

Choice C rationale

Wearing a gown protects the caregiver’s clothing from contamination when assisting with activities like bathing. Gowns act as a barrier to prevent MRSA from contacting the caregiver's skin or clothes and being carried outside the patient’s room.

Choice D rationale

Taking the client outside the room increases the risk of spreading MRSA to others. While a mask may protect against respiratory droplets, it does not prevent the transmission of MRSA via contact with contaminated surfaces or the patient’s skin.

A. Monitor for at least 150 mL of drainage every hour. B. Replace the unit when the drainage chamber is full. C. Clamp the tube for 30 min every 8 hr. D. Pin the tubing to the client's bed sheets.

Correct Answer is B

Explanation

Choice A rationale

Monitoring for at least 150 mL of drainage every hour is excessive; the expected drainage is around 70-100 mL per hour. This amount indicates a potential complication.

Choice B rationale

Replacing the unit when the drainage chamber is full is correct to maintain the efficiency of the closed-chest tube drainage system and prevent overflow.

Choice C rationale

Clamping the tube for 30 minutes every 8 hours can cause tension pneumothorax and is not recommended.

Choice D rationale

Pinning the tubing to the client's bed sheets can cause kinks and obstruction, which can lead to complications.

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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.)

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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.)