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."

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 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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Extravasation B. Phlebitis C. Infiltration D. Venous spasm

Correct Answer is B

Explanation

Choice A Reason:
Extravasation is incorrect. This occurs when the intravenous fluid leaks into the surrounding tissue rather than remaining within the vein. It may cause swelling, pain, and potential tissue damage due to the infused solution's irritant effects.
Choice B Reason:
Phlebitis is correct. Phlebitis refers to the inflammation of a vein often characterized by redness, warmth, swelling, and tenderness along the course of the vein. It can occur due to various reasons, including irritation from the IV catheter, chemical irritation from the infused solution, or infection.
Choice C Reason:
Infiltration is incorrect. Infiltration refers to the inadvertent leakage of the infused fluid into the surrounding tissues. It may cause swelling and discomfort but doesn't typically present with redness and inflammation along the vein.
Choice D Reason:
Venous spasm is incorrect. Venous spasm involves the involuntary contraction of the vein, which can occur in response to irritation or trauma. It may cause temporary difficulty in IV access but does not usually present with redness and inflammation along the vein as the primary signs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring for an infusion reaction for a client who is receiving a dose of IV amphotericin B. Which of the following findings should indicate to the nurse that the client is experiencing an acute infusion reaction?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving intravenous therapy and observes redness and inflammation along the vein. The nurse should identify this finding as which of the following complications of IV therapy?

Correct Answer is B

Explanation

A nurse is reviewing the plan of care with a client who has a new prescription for lovastatin. Which of the following statements by the client should indicate to the nurse a need for further assessment?

A nurse is transcribing a new prescription for a client which states, "Diphenhydramine 50 mg NOW." Which of the following actions should the nurse take?

A nurse is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the nurse identify as an early indication of medication toxicity?

A nurse is mixing regular insulin and NPH insulin in the same syringe prior to administering it to a client who has diabetes mellitus. Which of the following actions should the nurse take first?

A nurse realizes that they failed to administer a medication that was due 4 hr ago to a client. Which of the following actions should the nurse take first?

A nurse is caring for a client who is taking lithium and reports starting a new exercise program. The nurse should assess the client for which of the following electrolyte imbalances?

A nurse is providing discharge dietary teaching to a client who has a new prescription for theophylline. Which of the following instructions should the nurse include?

A nurse is preparing to administer nitroglycerin topical ointment to a client. Which of the following actions should the nurse plan to take?