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 ["A","C","E","G"]
Explanation
Choice A rationale
Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.
Choice B rationale
Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.
Choice C rationale
Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.
Choice D rationale
Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.
Choice E rationale
Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.
Choice F rationale
Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.
Choice G rationale
Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.