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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["400"]
Explanation
Step 1: Determine the Total Volume Needed
- Supplied concentration: 300 mg/100 mL
- Prescribed dose: 300 mg
- Total volume needed = 100 mL
Step 2: Convert Time to Hours
- Prescribed infusion time = 15 minutes
- 15 minutes ÷ 60 minutes/hour = 0.25 hours
Step 3: Calculate the Infusion Rate (mL/hr)
- Infusion rate = Total volume (mL) ÷ Time (hours)
- Infusion rate = 100 mL ÷ 0.25 hours
- Infusion rate = 400 mL/hr
The nurse should set the IV pump to deliver cimetidine at 400 mL/hr (rounded to the nearest whole number).
Correct Answer is C
Explanation
A. A vein that feels hard to the touch:
A vein that feels hard to the touch may indicate thrombosis or inflammation and is not a suitable site for catheter insertion.
B. A vein in the client's dominant arm:
The choice of arm may depend on the client's preference, but it is not a strict rule. The nurse can choose a suitable vein in either arm based on factors such as accessibility and vein condition.
C. A vein proximal to the previous site:
This is the correct answer. Placing the catheter proximal (above or upstream) to the previous site helps minimize the risk of complications such as infiltration and thrombophlebitis at the new site. It allows for optimal vein health and reduces the likelihood of complications associated with repeated punctures in the same area.
D. A vein on the client's wrist:
Veins on the wrist may be smaller and more prone to complications. It is generally recommended to choose larger, more accessible veins for catheter insertion.
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