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 B
Explanation
Choice A rationale
Whether the popsicles contain pulp or fruit is not relevant to the clear liquid diet, which focuses on the clarity and digestibility of the liquids.
Choice B rationale
The color and flavor of gelatin used are important because certain colors, especially red or purple, can interfere with medical tests and are often avoided in clear liquid diets.
Choice C rationale
If the popsicles are completely frozen is not relevant to the dietary restrictions. The focus should be on the ingredients and their suitability for a clear liquid diet.
Choice D rationale
The number of popsicles available does not impact their suitability for the child’s diet. The nurse should focus on the content and appropriateness of the popsicles.
Correct Answer is D
Explanation
Choice A rationale
Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.
Choice B rationale
Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.
Choice C rationale
Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.