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
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position can help with breathing but does not directly address the issue of dry mucous membranes due to mouth breathing and refusal to eat or drink.
Choice C rationale
Keeping mucous membranes moist is crucial for comfort and preventing complications such as dryness and cracking, which can lead to infections. This intervention directly addresses the client’s symptoms and promotes comfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Correct Answer is C
Explanation
Choice A rationale
Offering therapeutic support and comfort to a grieving family does not typically require the structured communication format of SBAR. This interaction is more about providing emotional support and empathy rather than conveying specific clinical information.
Choice B rationale
Obtaining clarification from a client’s healthcare power-of-attorney may involve detailed discussions, but it is not the primary context for SBAR. SBAR is designed for concise, structured communication about clinical situations.
Choice C rationale
Reporting a change in a client’s condition to the healthcare provider is the ideal scenario for using SBAR. This format ensures that critical information is communicated clearly and efficiently, which is essential for patient safety and effective clinical decision-making.
Choice D rationale
Completing discharge teaching to a client and family members involves providing comprehensive education and instructions, which is not the primary purpose of SBAR. SBAR is more suited for brief, focused communication about specific clinical issues.