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 reduce the risk of bleeding or hematoma formation, especially with subcutaneous injections. This practice aids in minimizing bleeding at the injection site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Furosemide is not correct. Furosemide is a diuretic used to treat conditions like heart failure and edema by increasing urine output. It is not a contraindication for sildenafil. However, it's essential to monitor blood pressure when these medications are used together, as both can potentially lower blood pressure.
Choice B Reason:
Albuterol is not correct. Albuterol is a bronchodilator commonly used to treat asthma and other respiratory conditions. It doesn't have direct contraindications with sildenafil for erectile dysfunction. Although both medications can cause some cardiovascular effects, they are not typically considered contraindications for each other.
Choice C Reason:
Indomethacin is not correct. Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation and pain. While it can have effects on blood pressure and the cardiovascular system, it is not a direct contraindication for sildenafil specifically for erectile dysfunction.
Choice D Reason:
Nitroglycerin is correct. Nitroglycerin is a contraindication for sildenafil. Both medications can cause a significant drop in blood pressure. When taken together, they can potentiate each other's effects, leading to a severe decrease in blood pressure, which can be dangerous and potentially life-threatening. Therefore, individuals using nitroglycerin or any nitrate medications should not take sildenafil or other medications for erectile dysfunction due to the risk of hypotension (dangerously low blood pressure).
Correct Answer is C
Explanation
Choice A Reason:
Ondansetron is incorrect. Ondansetron is an anti-nausea medication commonly used in cancer patients to manage nausea and vomiting, often caused by chemotherapy. It's not typically contraindicated or known to interact significantly with morphine administered via a PCA pump. This combination is often used to manage both pain and associated symptoms in cancer patients.
Choice B Reason:
Acetaminophen is incorrect. Acetaminophen is a pain reliever and fever reducer that doesn't typically interact significantly with morphine administered via a PCA pump. It's often used concurrently with other pain medications to manage discomfort in cancer patients. There isn't a known significant interaction between acetaminophen and morphine when used appropriately.
Choice C Reason:
Nalbuphine is correct. Nalbuphine is an opioid analgesic, similar to morphine, and administering it concurrently with morphine could potentially lead to opioid overdose or increased risk of opioid-related side effects such as respiratory depression. Thus, it's crucial to clarify with the provider whether there might be a potential interaction or if both medications are indeed necessary in this specific clinical scenario.
Choice D Reason:
Insulin glargine is incorrect. Insulin glargine is a long-acting insulin used to manage blood sugar levels in individuals with diabetes. While its interaction with morphine isn't typically a concern, it's essential to monitor blood sugar levels closely in individuals receiving opioids like morphine, as opioids can affect glucose metabolism and may necessitate adjustments in insulin dosage.
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