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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.

Answer and Explanation

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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A. Placing a client in restraints without having a healthcare provider’s order. B. Administering the medication to a client behind a closed curtain. C. Informing a client that the medication being administered is a vitamin. D. Enlisting security personnel to assist with restraining the client.

Correct Answer is A

Explanation

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

A. Drink a mixture of warm water, whiskey, and honey at bedtime. B. Establish a regular time for going to bed and getting up. C. Ask the healthcare provider for a mild sedative for bedtime. D. Take an afternoon nap to make up for missed sleep. E. Avoid drinking caffeinated beverages late in the day.

Correct Answer is ["B","E"]

Explanation

Choice A rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.

Choice B rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.

Choice C rationale

Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep

Choice D rationale

Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.

Choice E rationale

Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.

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The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

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Correct Answer is A

Explanation

Correct Answer is ["B","E"]

Explanation

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Take full exam for free The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

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A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Correct Answer is A

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["B","E"]

Explanation

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The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?