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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?

A.

Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus.

B.

Rotate injections between the abdomen and gluteal areas.

C.

Massage the injection site to increase absorption.

D.

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Providing client-focused information is essential, but it does not confirm that the client has understood the critical information. It is a part of the teaching process but not a confirmation strategy.

Choice B rationale

Reinforcing key points with the client helps emphasize important information but does not ensure that the client has learned and understood it. It is a supportive strategy rather than a confirmation method.

Choice C rationale

Observing the client’s body language can provide clues about their understanding and comfort level but is not a definitive way to confirm learning. It should be used in conjunction with other strategies.

Choice D rationale

Asking the client for learning feedback is the most effective strategy for confirming that the client has understood the critical information. It encourages active participation and allows for real-time clarification.

Correct Answer is C

Explanation

Choice A rationale

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

Choice B rationale

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

Choice C rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.

Choice D rationale

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading.

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