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 D

Explanation

Rationale:
A. Prepare the sterile field for a urinary catheter insertion: Setting up a sterile field requires knowledge of aseptic technique and is within the scope of a nurse or PN, not a UAP due to the risk of contamination and infection.

B. Begin wound care for a client after an appendectomy: Wound care involves assessment and sometimes sterile dressing changes, both of which require nursing judgment and are outside the UAP’s scope of practice. This task should be assigned to a licensed nurse.

C. Monitor an IV infusion rate on an established schedule: Monitoring IV infusions requires an understanding of fluid dynamics, potential complications, and may involve calculations. This is a nursing task and not appropriate for UAP delegation.

D. Anchor an inserted urinary catheter in place with tape: Securing a urinary catheter after insertion is a non-invasive, routine task that does not require clinical judgment, making it appropriate for delegation to a trained UAP under supervision.

A. Duration of sensation. B. Precipitous activiity. C. Time of last analgesic. D. Gait coordination.

Correct Answer is A

Explanation

Rationale:
A. Duration of sensation: This helps to determine if the symptoms are acute, intermittent, or continuous, which can provide clues about the severity of nerve compression or irritation. Changes in duration, frequency, or intensity can indicate worsening nerve impingement or the development of a new neurological deficit requiring immediate attention.

B. Precipitous activity: While it's useful to know what activity triggered the symptoms, this is secondary to understanding the timeline and progression of neurological signs, which carry more urgency.

C. Time of last analgesic: Pain control is important, but the priority is evaluating potential nerve compromise. Numbness and tingling may reflect compression or damage that cannot be addressed by analgesia alone.

D. Gait coordination: Assessing gait coordination is important to evaluate the functional impact of the neurological symptoms, which could indicate more severe nerve compression affecting motor pathways. However, it is an assessment of a motor function. The client is describing sensory symptoms.

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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?

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