Which is an accurate nursing action when administering ...

[tichca]

Which is an accurate nursing action when administering subcutaneous enoxaparin, a low-molecular-weight heparin product?
 
  a. Expel the air bubble from the prefilled syringe.
  b. Leave the needle in place for 10 seconds after injection.
  c. Administer the medication into the deltoid muscle.
  d. Massage the site after injection to increase absorption.

Question 2

A patient is receiving IV heparin therapy. The aPTT is 90; the laboratory control is 30 seconds. Which nursing intervention is most accurate?
 
  a. Document in the nursing notes that these results are within therapeutic range.
  b. Note the RBC count and wait for the health care provider to make the next round to discuss all laboratory values.
  c. Stop the heparin drip.
  d. Assess the patient for signs and symptoms of decreased sensorium.

[mbcrismon]

Answer to Question 1

ANS: B
The needle is left in place for 10 seconds after injection. Air is not expelled from the prefilled syringe. This medication is not administered intramuscularly. The site should not be massaged to increase absorption.

Answer to Question 2

ANS: C
Heparin dosage is considered to be in the normal therapeutic range if the aPTT is 1.5 to 2.5 times the control value. The patient's aPTT value is above the therapeutic range, which puts her at risk for hemorrhage. The most appropriate nursing action would be to stop the heparin drip. These results cannot be documented as being within the normal therapeutic range. RBC count and mental status are not relevant in assessing therapeutic response to anticoagulation.

[tichca]

Thanks

[mbcrismon]

Welcome