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.

Check the medication administration record to verify the client's allergies.

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.

Ensure an air bubble is present in the prefilled enoxaparin syringe.

Answer and Explanation

The Correct Answer is B, E, A, D, C

B. Check the medication administration record to verify the client's allergies. Before preparing or administering any medication, the nurse must verify the client’s medication order and allergies to ensure safety. E. Ensure an air bubble is present in the prefilled enoxaparin syringe. The prefilled syringe contains an air bubble that should remain to ensure the entire dose is administered and to prevent medication from tracking back through the tissue. A. Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. Enoxaparin should be administered in the subcutaneous tissue of the abdomen, avoiding areas near the umbilicus to reduce the risk of irritation and bruising. D. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. Pinching the skin ensures the medication is delivered into the subcutaneous tissue, and injecting at a 90° angle minimizes pain and ensures proper technique. C. Slowly inject the medication into the site without aspirating. Aspiration is not necessary for subcutaneous injections. Slowly injecting reduces discomfort and ensures proper absorption.

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Correct Answer is D

Explanation

Choice A Reason:

Leave the television on in the client's room is incorrect. Leaving the television on doesn't directly address the safety concern of falls. While it might provide some distraction or comfort, it doesn't mitigate the risk of the client attempting to leave the bed unsafely.

Choice B Reason:

Raise all four side rails while the client is in bed is incorrect. Using all four side rails can be considered a form of restraint and is generally not recommended due to the risk of entrapment and potential psychological distress for the client. It can also increase the risk of agitation and attempts to climb over the rails, potentially resulting in falls.

Choice C Reason:

Move the overbed table away from the bed is incorrect. Moving the overbed table might reduce clutter around the bed area, but it doesn't directly address the risk of falls for a client with dementia. It's more about optimizing the environment than specifically addressing the safety concern related to the client's condition.

Choice D Reason:

Apply a motion sensor mat to the client's bed is correct. For an older adult with dementia at risk for falls, a motion sensor mat can be an effective safety measure. It alerts the staff when the client attempts to get out of bed, allowing for timely intervention to prevent falls. This helps the nursing staff respond promptly, ensuring the client's safety.

A. Elevate the head of the client's bed for 1 hr. after the feeding. B. Administer the feeding solution at a cold temperature. C. Rotate the jejunostomy tube once per day. D. Flush the tube with 90 mL of sterile water before and after the feeding.

Correct Answer is A

Explanation

Choice A Reason:

Elevate the head of the client's bed for 1 hr. after the feeding is appropriate. This action helps minimize the risk of aspiration. Elevating the head of the bed (typically at least 30 to 45 degrees) can reduce the chance of reflux and aspiration of the feeding solution into the lungs. This position should ideally be maintained for about 1 hour after the feeding to aid digestion and reduce the risk of complications.

Choice B Reason:

Administering the feeding solution at a cold temperature is inappropriate. Feeding solutions are generally administered at room temperature or slightly warmed to prevent discomfort and minimize the risk of altering the client's core body temperature. Cold temperatures can cause discomfort or cramping and might affect the absorption of the nutrients. Therefore, administering the feeding solution at a cold temperature is not recommended.

Choice C Reason:

Rotating the jejunostomy tube once per day is inappropriate. Rotating the jejunostomy tube is not typically part of routine care. Tube rotation can cause discomfort, irritation, and potential injury to the gastrointestinal tract. Tubes should be secured properly to prevent movement but not rotated unless specifically instructed by a healthcare provider for a particular reason, such as checking for proper tube placement.

Choice D Reason:

Flushing the tube with 90 ml of sterile water before and after the feeding is inappropriate.

Flushing the tube with sterile water before and after the feeding helps ensure the patency of the tube and prevents clogging. It's a standard procedure to clear the tube and maintain its function

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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

Naxlex Comprehensive Predictor Exams

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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