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 A

Explanation

Choice A Reason:

Older adults are at increased risk for falls due to decreased vision, balance issues, and decreased reaction time. Placing white or brightly colored tape on the edges of stairs enhances visibility, reducing the risk of missteps and falls.

Choice B Reason:

Placing area rugs on wooden floors is not appropriate. Area rugs on wooden floors can pose a tripping hazard, especially for older adults who might have mobility issues. They can easily slip or trip on loose rugs. Securing rugs with non-slip backing or removing them entirely is a better safety measure.

Choice C Reason:

Running wires and cords under carpeting is not appropriate. Running wires and cords under carpeting can create tripping hazards and increase the risk of electrical issues, including potential overheating and fire hazards. It's safer to secure cords along walls or use cord covers to prevent tripping and reduce potential electrical hazards

Choice D Reason:

Heating systems should be inspected annually to prevent carbon monoxide poisoning and fire hazards. An annual inspection is recommended, especially for older adults who may have impaired smell or cognition, making them less likely to detect gas leaks or heating malfunctions.

A. Ensure the blinds in the client's room remain open. B. Place the client in a room near the nurses' station. C. Play quiet music in the client's room. D. Break up nursing care into small, frequent sessions.

Correct Answer is D

Explanation

Choice A Reason:

Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.

Choice B Reason:

Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.

Choice C Reason:

Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.

Choice D Reason:

Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.

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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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