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
Stating that the healthcare provider will share the information does not address the legal status of the emancipated minor and may delay the communication of important information.
Choice B rationale
Telling the parents that their child’s medical information is none of their business is not respectful and does not provide a clear explanation of the legal situation.
Choice C rationale
Offering to give the results to the parents as soon as they are available does not respect the legal autonomy of the emancipated minor.
Choice D rationale
Explaining that medical information can only be given to the client because they are legally an adult is the best response. It respects the legal status of the emancipated minor and their right to make their own healthcare decisions
Correct Answer is ["A","B","C","G","H"]
Explanation
Choice A rationale
Measuring vital signs at 1500 is essential because the client has a temperature of 102°F (38.9°C) at 1400, indicating a potential infection or other condition that needs monitoring.
Choice B rationale
At 1600, it is important to measure vital signs to assess the client’s response to any interventions provided for the elevated temperature.
Choice C rationale
At 1800, continuous monitoring of vital signs helps detect any changes in the client’s condition and ensures timely intervention if needed.
Choice G rationale
Measuring vital signs at 1400 provides a baseline for comparison with subsequent readings, especially given the elevated temperature.
Choice H rationale
Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.