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
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Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.
Correct Answer is A
Explanation
Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
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