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

Infiltration occurs when IV fluid leaks into the surrounding tissue, causing edema, coolness, and tenderness at the insertion site. This can lead to discomfort and complications if not promptly addressed.

Choice B rationale

Nerve damage from IV therapy usually presents as pain, numbness, or tingling rather than edema and coolness. It results from inadvertent injury to a nerve during catheter insertion or from prolonged pressure on a nerve.

Choice C rationale

Phlebitis is inflammation of the vein, characterized by redness, warmth, and tenderness along the vein. It does not typically cause coolness or extensive edema.

Choice D rationale

Infection at the catheter insertion site usually presents with redness, warmth, and purulent discharge, rather than coolness and edema. Tenderness can be present, but other signs of infection would also be observed.

A. "I shouldn't travel by plane because of airport security.”. B. "I should have an MRI, rather than a CAT Scan, if necessary.”. C. "I'll hold my cell phone against the ear on the opposite side of my body.”. D. "I'll make sure I stay away from microwave ovens.”.

Correct Answer is C

Explanation

Choice A rationale

Traveling by plane is safe for individuals with pacemakers. Security procedures at airports can be managed with proper precautions and communication with security staff.

Choice B rationale

MRIs are generally contraindicated for individuals with pacemakers due to the strong magnetic fields. CAT scans are usually a safer alternative.

Choice C rationale

Holding the cell phone on the opposite side of the pacemaker is recommended to avoid potential interference with the device.

Choice D rationale

Modern microwave ovens are well shielded and do not pose a risk of interference with pacemakers. Individuals with pacemakers can safely use microwaves.

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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.)

Nursing Test Bank

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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.)