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 B
Explanation
Choice A Reason:
Dry cough is incorrect. While cough can be a side effect of amphotericin B, it's not a hallmark sign of an acute infusion reaction.
Choice B Reason:
Fever is correct. Acute infusion reactions to amphotericin B can manifest in various ways, and fever is a common sign indicating an immediate adverse reaction during the infusion. Other potential signs of an acute infusion reaction may include chills, rigors, hypotension, flushing, headache, or nausea.
Choice C Reason:
Pedal edema is incorrect. Swelling of the feet or pedal edema is not a typical manifestation of an acute infusion reaction to amphotericin B.
Choice D Reason:
Hyperglycemia is incorrect. Increased blood glucose levels (hyperglycemia) are not commonly associated with an acute infusion reaction to amphotericin B. However, amphotericin B may have effects on electrolytes and kidney function that could indirectly impact glucose levels.
Correct Answer is C
Explanation
Choice A Reason:
Determine factors that led to the omission. Understanding why the dosage was missed is crucial. Was there a specific reason such as an interruption, conflicting priorities, or confusion in the medication schedule? Identifying these factors can help prevent future omissions and improve the medication administration process.
Choice B Reason:
File an incident report. If the missed dosage poses any potential risk or deviation from the prescribed treatment plan, it's important to document the incident through an incident report. This ensures transparency and allows the healthcare team to address and learn from the situation.
Choice C Reason:
Report the missed dosage to the client's provider. Informing the client's healthcare provider about the missed dosage is crucial. The provider can assess the situation and provide guidance on whether any adjustments or additional steps are necessary to ensure the client's well-being.
Choice D Reason:
Assess the client for adverse reactions. Monitoring the client for any adverse reactions or changes in their condition is essential after a missed dosage. This observation helps detect any potential effects of the missed medication and allows for prompt intervention if needed.
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