The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
Expel the air in the prefilled syringe prior to injection.
Rotate injections between the abdomen and gluteal areas.
Massage the injection site to increase absorption.
Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus.
The Correct Answer is D
Choice A rationale
Expelling the air in the prefilled syringe prior to injection is not recommended for low molecular weight heparin (LMWH) administration. The air bubble in the prefilled syringe helps ensure the entire dose is delivered and prevents leakage of the medication. Removing the air bubble can lead to an incomplete dose and reduced efficacy of the medication.
Choice B rationale
Rotating injections between the abdomen and gluteal areas is not recommended for LMWH administration. The preferred site for LMWH injections is the abdominal area, specifically at least 2 inches (5.1 cm) from the umbilicus. This site provides better absorption and reduces the risk of complications such as hematoma formation.
Choice C rationale
Massaging the injection site to increase absorption is not recommended for LMWH administration. Massaging the site can cause bruising and hematoma formation, which can be painful and may affect the absorption of the medication. It is important to avoid massaging the injection site to minimize these risks.
Choice D rationale
Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct instruction for LMWH administration. This site provides optimal absorption and reduces the risk of complications. The abdominal area has a good blood supply, which helps in the effective absorption of the medication. Additionally, injecting at least 2 inches (5.1 cm) from the umbilicus helps avoid the umbilical area, which is more prone to bruising and discomfort.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.
Choice B rationale
Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.
Choice C rationale
Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.
Choice D rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.
Correct Answer is D
Explanation
Choice A rationale
Beginning the collection the next day is not necessary. The 24-hour urine collection can be started immediately with the next void. Delaying the collection may cause unnecessary inconvenience and prolong the client’s hospital stay.
Choice B rationale
Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure that the collection starts with an empty bladder. Including the initial sample would result in inaccurate measurement of creatinine clearance.
Choice C rationale
Observing the sample for sediment is not relevant to the collection process for creatinine clearance. The focus should be on ensuring accurate timing and collection of all urine produced within the 24-hour period.
Choice D rationale
Starting the collection with the next void is the correct action. The 24-hour urine collection should begin with an empty bladder, and the first urine of the day is discarded. The time is noted, and all subsequent urine is collected for the next 24 hours. This ensures accurate measurement of creatinine clearance.