A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?
Select an injection site on the abdomen 5 cm (2 in) from the umbilicus.
Expel the air bubble in a prefilled syringe before injecting the medication.
Aspirate prior to injecting the medication.
Insert the needle at a 15° angle.
The Correct Answer is A
Choice A rationale: Selecting a site at least 5 cm (2 in) away from the umbilicus is essential because the tissue around the navel is often tougher and has altered vascularity, which can lead to inconsistent medication absorption.
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Choice B rationale: Air bubbles in prefilled syringes, such as those used for enoxaparin, should not be expelled. The air bubble is designed to be injected last to seal the medication within the subcutaneous tissue and prevent leakage.
Choice C rationale: Aspiration is no longer recommended for subcutaneous injections. There are no large blood vessels in the subcutaneous layer, and aspiration increases the risk of tissue trauma, hematoma formation, and client discomfort.
Choice D rationale: Subcutaneous injections should be administered at a 45° to 90° angle, depending on the amount of subcutaneous fat available. A 15° angle is used specifically for intradermal injections, such as TB skin tests.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.
Choice B rationale:
Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.
Choice C rationale:
Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.
Choice D rationale:
Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.
Correct Answer is C
Explanation
Choice A rationale:
Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.
Choice B rationale:
Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.
Choice C rationale:
Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.
Choice D rationale:
Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.
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