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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Correct Answer is C
Explanation
Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.
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.