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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?

A.

"I will check the client's INR before administering the heparin."

B.

"I will aspirate before administering the heparin."

C.

"I will massage the site after the injecting the heparin."

D.

"I will apply pressure for 1 minute after the injection."

Answer and Explanation

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.
 


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Related Questions

Correct Answer is D

Explanation

Choice A Reason:
Discard the medication if it is yellow is incorrect. While amphotericin B lipid complex can have a yellowish color, it's important to follow specific guidelines provided by the manufacturer or pharmacy regarding any discoloration or changes in the medication's appearance. Discoloration could indicate degradation or contamination, and it's crucial to adhere to specific institutional policies in such cases.
Choice B Reason:
Administer the medication over 2 hr is incorrect. Amphotericin B lipid complex is usually given over a longer duration (e.g., several hours) due to the potential for infusion-related reactions. Intermittent IV bolus administration over 2 hours might not be appropriate and can increase the risk of adverse reactions.
Choice C Reason:
Use a gravity flow set is incorrect. For medications like amphotericin B lipid complex, which often require precise infusion rates and careful monitoring, using an IV infusion pump is usually recommended instead of a gravity flow set. An infusion pump allows for more accurate control of the infusion rate and reduces the risk of errors.
Choice D Reason:
Prime the tubing with 0.9% sodium chloride is correct. Amphotericin B lipid complex should be administered according to specific instructions and precautions. Priming the IV tubing with 0.9% sodium chloride helps ensure that the medication is effectively delivered to the patient and that the medication is not affected by remnants of previous IV solutions in the tubing.

Correct Answer is ["60"]

Explanation

Step 1: Determine the Lidocaine Concentration

  • The solution contains 2 grams (2000 mg) of lidocaine in 500 mL.
  • To find the amount of lidocaine per mL:
    2000 mg ÷ 500 mL = 4 mg/mL

Step 2: Calculate the Total Dose per Hour

  • The prescribed infusion rate is 4 mg per minute.
  • In 1 hour (60 minutes), the total dose is:
    4 mg/min × 60 min = 240 mg/hr

Step 3: Determine the Infusion Rate in mL/hr

  • Since each mL contains 4 mg of lidocaine:
    240 mg ÷ 4 mg/mL = 60 mL/hr

The nurse should set the IV pump to 60 mL/hr for the continuous IV infusion of lidocaine at a rate of 4 mg/min.

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