The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?
Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus.
Rotate injections between the abdomen and gluteal areas.
Expel the air in the prefilled syringe prior to Injection.
Massage the injection site to increase absorption.
The Correct Answer is A
A. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus:
This instruction is accurate and appropriate for the administration of low molecular weight heparin subcutaneously. Injecting into the abdominal area at least 2 inches (5.1 cm) away from the umbilicus is a commonly recommended site for subcutaneous injections due to the availability of subcutaneous tissue and the reduced risk of injury to underlying structures.
B. Rotate injections between the abdomen and gluteal areas:
While rotation of injection sites is important to prevent tissue damage and lipodystrophy, for subcutaneous injections of low molecular weight heparin, the abdomen is typically the preferred site due to better absorption and reduced risk of complications. Therefore, rotating between the abdomen and gluteal areas may not be necessary or recommended for this specific medication.
C. Expel the air in the prefilled syringe prior to injection:
Expelling air from the prefilled syringe is a standard practice to ensure accurate dosing and prevent air embolism, but it is not specific to the administration of low molecular weight heparin. This instruction should be included in general injection technique education but is not specific to the administration of this medication.
D. Massage the injection site to increase absorption:
Massaging the injection site after administration of low molecular weight heparin is not recommended, as it can increase the risk of bleeding or hematoma formation at the injection site. Massaging the site is generally contraindicated for anticoagulant injections to avoid disrupting the clotting process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Warn the colleague that copying health information is unlawful:
While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.
B. Send an email to facility administrators reporting the action:
Reporting the colleague's actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.
C. Communicate the colleague's activities to the unit charge nurse:
This is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.
D. Dispose the copies and continue with client care assignments:
While disposing of the copies may prevent further unauthorized access to patient information, it does not address the issue of the colleague's inappropriate handling of the records. It's essential to report the incident to the appropriate authority for further investigation and follow-up.
Correct Answer is A
Explanation
A. Positive external places:
Guided imagery typically involves directing the client to visualize calming and peaceful external environments, such as a beach, forest, or other positive, serene places. This technique helps divert the client's attention away from pain and promotes relaxation.
B. Emotional reflection:
Emotional reflection may be part of the guided imagery process, especially if it helps the client process and cope with their emotions related to chronic pain. However, the primary focus of guided imagery is typically on visualization techniques rather than emotional reflection alone.
C. Motivational phrases:
Motivational phrases can be helpful in some relaxation techniques, but in guided imagery for chronic pain management, the emphasis is usually on visualizing soothing images or scenarios rather than repeating motivational phrases.
D. Tranquil sounds:
Tranquil sounds may be part of a relaxation strategy, but guided imagery specifically involves visualizing calming scenes, not just focusing on sounds.
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