A charge nurse is teaching a newly licensed nurse about administering heparin to a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I will check the client's INR before administering the heparin."
"I will aspirate before administering the heparin."
"I will massage the site after the injecting the heparin."
"I will apply pressure for 1 minute after the injection."
The Correct Answer is D
Choice A Reason:
. "I will check the client's INR before administering the heparin." Is incorrect. Checking the client's INR (International Normalized Ratio) is essential, but it's more applicable for monitoring anticoagulants like warfarin, not heparin. Heparin's effect is typically monitored via activated partial thromboplastin time (aPTT) or anti-Xa levels, not INR.
Choice B Reason:
"I will aspirate before administering the heparin." Is incorrect. Aspirating before administering heparin injections is not necessary because the medication is given subcutaneously or intravenously and not into a blood vessel.
Choice C Reason:
"I will massage the site after injecting the heparin." Is incorrect. Massaging the site after injecting heparin could increase the risk of bruising or hematoma formation at the injection site. It's generally advised to avoid massaging the area after a heparin injection to prevent tissue trauma.
Choice D Reason:
"I will apply pressure for 1 minute after the injection." Is correct. Applying pressure to the injection site for about a minute after administering heparin helps minimize the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in reducing bleeding at the injection site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"I should notify my provider if my stools turn black." This is the appropriate statement. Ferrous gluconate is an iron supplement commonly prescribed to treat or prevent iron deficiency anemia. When taking iron supplements, it's common for stools to become darker or even black in color. This change in stool color is due to the iron and is generally harmless. However, it's essential to inform the healthcare provider about this change because it can also indicate bleeding in the gastrointestinal tract, which requires evaluation.
Choice B Reason:
Taking an antacid with iron supplements can interfere with iron absorption. Antacids may decrease the absorption of iron in the stomach, so it's not recommended to take them together.
Choice C Reason:
While staying upright after taking certain medications can help prevent esophageal irritation or reflux, it's not specifically required with ferrous gluconate.
Choice D Reason:
Taking iron supplements with milk is also not recommended as milk and calcium-containing products can inhibit the absorption of iron. It's generally best to take iron supplements on an empty stomach or with vitamin C to enhance absorption, unless otherwise instructed by the healthcare provider.
Correct Answer is A
Explanation
Choice A Reason:
Apply the patch to a hairless area of the skin is correct. Nitroglycerin patches should be applied to a clean, hairless area of the skin to ensure proper absorption of the medication. Hair can interfere with the patch's adherence and the absorption of nitroglycerin into the bloodstream. The site chosen should be rotated to prevent skin irritation or tolerance development. Commonly used areas include the chest, upper arms, or torso, but it's important to follow specific instructions provided by the healthcare provider.
Choice B Reason:
Apply a 4x4 dressing over the patch is incorrect. Covering the nitroglycerin patch with a dressing may interfere with its absorption and effectiveness. These patches are designed to be applied directly to the skin without covering.
Choice C Reason:
Apply the patch to the same site every 24 hr is incorrect. Repeatedly applying the patch to the same site increases the risk of skin irritation or tolerance to the medication. It's crucial to rotate patch sites to avoid these issues.
Choice D Reason:
Apply the patch to a bony prominence on the chest is incorrect. Nitroglycerin patches should not be placed on bony prominences because these areas can be uncomfortable and may not provide optimal absorption. Instead, they are typically applied to relatively flat, hairless areas of the skin.
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