The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement?

Hold the skin fold throughout the injection.

Insert the needle at a 90 degree angle.

Retain the air bubble in the syringe barrel.

Massage the area after injection.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Hold the skin fold throughout the injection: Pinching the skin may be helpful to avoid intramuscular injection, especially in thin clients, but it's not required throughout the entire injection process. It is not the most critical technique compared to air bubble retention.

B. Insert the needle at a 90 degree angle: A 90-degree angle is appropriate for clients with sufficient subcutaneous tissue, but in thinner clients a 45-degree angle may be safer. The angle depends on the client’s body habitus and is not universally required.

C. Retain the air bubble in the syringe barrel: The air bubble helps ensure that the full dose is delivered and prevents medication from tracking through subcutaneous tissue, which could cause bruising. It should not be expelled before administering enoxaparin.

D. Massage the area after injection: Massaging the site can increase the risk of bruising and tissue irritation with anticoagulants like enoxaparin. Gentle pressure may be applied if needed, but the site should not be massaged.

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Correct Answer is ["A","E"]

Explanation

Rationale:

A. Separate fluids from meals: Fluids should be consumed at least 30 minutes before or after meals to prevent gastric overdistention and dumping syndrome, which are common after bariatric surgery.

B. Plan meals to include rice porridge: Rice porridge is high in simple carbohydrates, which can cause dumping syndrome and rapid gastric emptying. It is not ideal post-surgery.

C. Eliminate acidic food choices: Acidic foods like citrus or tomatoes may cause discomfort, but they are not universally contraindicated. Tolerance varies by individual, so elimination is not routinely necessary.

D. Offer more bread and cheese: Bread can form a sticky bolus that’s hard to swallow post-op, and cheese is high in fat. Both can cause discomfort or intolerance early in recovery.

E. Provide small frequent meals: After bariatric surgery, the stomach’s capacity is reduced, so clients need to eat small, frequent meals to meet nutritional needs and prevent nausea or vomiting.

A. The client should be monitored closely for persistent nausea or vomiting. B. A large number of family members are in the surgical waiting area. C. A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible. D. Surgical dressing is clean, dry, and intact and neurovascular status is within normal limits. E. Client history includes heart failure and aphasia from a previous stroke.

Correct Answer is ["C","D","E"]

Explanation

Rationale:
A. The client should be monitored closely for persistent nausea or vomiting: While relevant, this is a nursing action and not critical SBAR content unless complications arise. It's not essential in a handoff unless persistent or severe.

B. A large number of family members are in the surgical waiting area: This is not directly relevant to the client’s clinical condition or care priorities, and does not belong in an SBAR handoff unless family poses an immediate concern.

C. A patient controlled analgesic (PCA) pump is prescribed and needs to be started as soon as possible: This is critical treatment information for continuity of pain management and should be communicated clearly during the SBAR handoff.

D. Surgical dressing is clean, dry, and intact and neurovascular status is within normal limits: Postoperative wound and neurovascular assessment findings are essential for monitoring surgical outcomes and early complications.

E. Client history includes heart failure and aphasia from a previous stroke: Medical history directly influences postoperative care decisions and risk for complications; it must be included in the background section of SBAR.

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The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.

Correct Answer is ["A","E"]

Explanation

Correct Answer is ["C","D","E"]

Explanation

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