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 D

Explanation

A. Potassium chloride 10 mEq/hr:
While potassium replacement is crucial in DKA, initiating it before fluid resuscitation can lead to further complications. Insulin administration can drive potassium back into cells, potentially causing hypokalemia. Fluid resuscitation helps address dehydration and electrolyte imbalances.
B. Bicarbonate by IV infusion:

Bicarbonate therapy is generally reserved for severe cases of acidosis, and its use in DKA is controversial. In this scenario, the blood glucose level is not significantly elevated, and the focus should be on fluid resuscitation and insulin administration.
C. Subcutaneous insulin injections:
While insulin is a critical component of DKA management, it should be administered intravenously for faster and more precise control of blood glucose levels. Subcutaneous insulin injections are not the initial route of administration in DKA.
D. 0.9% sodium chloride 15 mL/kg/hr:
This is the correct answer. The first step in DKA management is fluid resuscitation with isotonic saline (0.9% sodium chloride). The goal is to address dehydration, restore intravascular volume, and improve perfusion. Insulin therapy and other interventions follow fluid resuscitation.

A. Omit over-the-counter medications from the at-home medication list. B. Include medications the client received in the acute setting but will no longer need after transfer. C. Compare the current list of medications to medications the client will receive after transfer D. Remove duplicate medications of different dosages from the reconciliation list

Correct Answer is D

Explanation

A. Omit over-the-counter medications from the at-home medication list:
Over-the-counter medications should be included in the medication reconciliation process to provide a comprehensive overview of all medications the client is taking. These can have interactions or implications for the client's overall health.
B. Include medications the client received in the acute setting but will no longer need after transfer:
Medications that the client will no longer need after transfer should be excluded from the reconciliation list to avoid confusion and unnecessary continuation of those medications.
C. Compare the current list of medications to medications the client will receive after transfer:
This is part of the medication reconciliation process. It is important to ensure continuity of care by comparing the current list of medications with the medications the client will receive after transfer. Any discrepancies or changes should be addressed.
D. Remove duplicate medications of different dosages from the reconciliation list:
This is the correct answer. Duplicate medications with different dosages can lead to confusion and errors. The reconciliation process involves identifying and resolving discrepancies, including duplicates, to ensure accuracy and safety in medication administration

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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?

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