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 C
Explanation
Choice A Reason:
Hypomagnesemia is incorrect. Lithium therapy itself is not a direct cause of hypomagnesemia. While exercise can affect magnesium levels to some extent, it's not a primary electrolyte imbalance that is typically associated with lithium use or considered a significant concern specifically due to lithium.
Choice B Reason:
Hypocalcemia is incorrect. Similarly, lithium therapy is not a direct cause of hypocalcemia. Exercise can affect calcium metabolism, but it's not a primary electrolyte imbalance typically associated with lithium use or considered a significant concern specifically due to lithium.
When a client taking lithium begins a new exercise program, the nurse should primarily assess for the risk of:
Choice C Reason:
Hyponatremia is correct. Lithium can affect the body's regulation of sodium, and excessive sweating due to increased exercise can lead to sodium loss. This combination can potentially contribute to the development of hyponatremia (low sodium levels). Therefore, when a client on lithium starts a new exercise regimen that may induce sweating, monitoring for signs of hyponatremia becomes crucial. Symptoms of hyponatremia can include confusion, headaches, nausea, and in severe cases, seizures or coma.
Choice D Reason:
Hypokalemia is incorrect. Lithium itself does not commonly cause hypokalemia. Exercise can lead to potassium loss through sweating, but hypokalemia is not the primary electrolyte imbalance typically associated with lithium use or considered a significant concern specifically due to lithium.
Correct Answer is A
Explanation
Choice A Reason:
Rotate the application site every week is correct. Rotating the application site is essential to prevent skin irritation or sensitization. Advising the client to apply the patch to a different area of clean, dry, non-hairy skin each time helps reduce the risk of skin irritation at the application site.
Choice B Reason:
The transdermal patch can cause insomnia is incorrect. Insomnia is a potential side effect of nicotine replacement therapy (NRT) patches, including transdermal nicotine patches, but it's not a universal side effect for everyone using the patch.
Choice C Reason:
Leave the patch in place for 8 hr. each day is incorrect. Transdermal nicotine patches are typically worn for 16–24 hours each day, depending on the specific product instructions. Leaving the patch on for a shorter duration might reduce its effectiveness in supporting smoking cessation.
Choice D Reason:
The transdermal patch releases nicotine rapidly into the bloodstream is incorrect. Transdermal nicotine patches deliver nicotine slowly through the skin into the bloodstream over an extended period rather than providing a rapid release. This gradual release helps reduce cravings and withdrawal symptoms associated with smoking cessation.
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