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 apply pressure for 1 minute after the Injection

I will massage the site after the injecting the heparin

I will aspirate before administering the heparin

None

Answer and Explanation

The Correct Answer is B

A. I will check the client's INR before administering the heparin:
Checking the International Normalized Ratio (INR) is more relevant for monitoring the effects of warfarin, not heparin. Heparin is typically monitored by activated partial thromboplastin time (aPTT) or anti-Xa levels.
B. "I will apply pressure for 1 minute after the injection:"
Applying gentle pressure to the injection site for about 1 minute after administering heparin is appropriate to prevent bleeding or bruising. Since heparin is an anticoagulant, there's an increased risk of bleeding at the injection site.
C. I will massage the site after injecting the heparin:
Massaging the site after injecting heparin is not recommended. It can increase the risk of hematoma formation. After subcutaneous injection, it is generally advised to avoid massaging the site.
D. I will aspirate before administering the heparin:
Aspiration is not recommended when administering heparin subcutaneously, as it can increase the risk of tissue damage and bruising. The nurse should inject the heparin without aspirating.

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Correct Answer is A

Explanation

A. Visual disturbances:
Visual disturbances, such as blurred or yellow-tinted vision, are common signs of digoxin toxicity. Clients should report any changes in vision promptly.
B. Potassium 4.4 mEq/L:
While electrolyte imbalances, particularly low potassium levels, can increase the risk of digoxin toxicity, a potassium level of 4.4 mEq/L is within the normal range and, by itself, does not indicate digoxin toxicity.
C. Insomnia:
Insomnia is not a typical sign of digoxin toxicity. Symptoms of toxicity are more likely to involve the gastrointestinal and visual systems.
D. Sudden weight gain:
Sudden weight gain can be a symptom of heart failure exacerbation but is not a direct indication of digoxin toxicity. Other signs, such as visual disturbances, are more specific to digoxin toxicity.

A. Dominant antecubital basilic vein B. Nondominant dorsal venous arch C. Dominant distal dorsal vein D. Nondominant forearm basilic vein

Correct Answer is D

Explanation

A. Dominant antecubital basilic vein:
While the basilic vein in the antecubital area is a suitable site, the nondominant arm is generally preferred when possible to minimize interference with the client's activities.
B. Nondominant dorsal venous arch:
The dorsal venous arch, located on the back of the hand or wrist, is a common site for peripheral IV catheter placement. It is preferred over other sites like the antecubital area due to lower risks of complications such as phlebitis and infiltration. Additionally, using the nondominant hand reduces interference with daily activities.
C. Dominant distal dorsal vein:
The dorsal veins are generally not the first choice for peripheral IV catheter placement due to the potential for complications such as infiltration.
D. Nondominant forearm basilic vein:

Nondominant forearm basilic vein: The basilic vein in the nondominant forearm is often a suitable site for peripheral IV catheter placement. The nondominant arm is preferred when feasible to minimize disruption of activities for the client. However, its preferred to start the IV infusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs; if infiltration occurs from the antecubital vein, the lower veins in the same arm usually should not be used for further puncture sites.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 indication of medication toxicity?

Correct Answer is A

Explanation

A nurse is preparing to initiate IV therapy for a client. Which of the following sites should the nurse use to place the peripheral IV catheter?

Correct Answer is D

Explanation

A nurse in the emergency department is admitting a client who has diabetic ketoacidosis and a blood glucose level of 100 mg/dl. Which of the following interventions should the nurse initiate first?

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A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?

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A nurse is caring for a client who has a peripheral IV catheter and a prescription for IV fluid replacement. The nurse should cover the Insertion site with which of the following types of dressing?