The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus.
Rotate injections between the abdomen and gluteal areas.
Massage the injection site to increase absorption.
Expel the air in the prefilled syringe prior to injection.
The Correct Answer is A
Choice A rationale
Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.
Choice B rationale
Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.
Choice C rationale
Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.
Choice D rationale
Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.
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Correct Answer is A
Explanation
Choice A rationale
Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.
Choice B rationale
Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.
Choice C rationale
Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.
Choice D rationale
Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.
Correct Answer is D
Explanation
Choice A rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice B rationale
Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.
Choice C rationale
Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.
Choice D rationale
Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.