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 E,B,D,C,A

Explanation

Choice Erationale

Clamping the catheter tubing distal to the sampling port for 15 minutes helps to ensure that enough urine is collected in the tubing for an adequate sample.

Choice B rationale

Wiping the sample port with an alcohol wipe and letting it dry is essential to prevent contamination of the specimen with microorganisms from the outside of the port.

Choice D rationale

Attaching a sterile needleless syringe to the sample port and aspirating the specimen prevents the introduction of infection and ensures that the sample is sterile.

Choice Crationale

Emptying the urine into a sterile container labeled with the client's identifiers ensures proper identification and prevents contamination of the sample.

Choice Arationale

Documenting in the client's electronic medical record that the specimen was sent to the laboratory provides a record of the procedure and helps ensure that the sample is properly processed.

A. The client's capillary refill is 3 seconds. B. The client's fingers are cool to the touch. C. The client reports severe itching under the cast. D. The client reports increased pain at the area of the fracture.

Correct Answer is D

Explanation

Choice A rationale

A capillary refill time of 3 seconds is slightly prolonged but not as concerning as other symptoms. Monitoring is warranted, but it is not an immediate priority.

Choice B rationale

Cool fingers can indicate reduced circulation, but it requires further assessment to determine its significance. Immediate attention is needed if accompanied by other severe symptoms.

Choice C rationale

Severe itching can be uncomfortable and may indicate skin irritation, but it is not typically a medical emergency.

Choice D rationale

Increased pain at the fracture site can indicate complications such as compartment syndrome, which requires immediate medical intervention to prevent permanent damage.

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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.)