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 C

Explanation

A. Discard the medication if it is yellow: Amphotericin B lipid complex is typically yellow in color. This is a normal characteristic of the medication, and it should not be discarded based on color. The nurse should be aware of the expected color and administer the medication as prescribed.
B. Administer the medication over 2 hr: Amphotericin B lipid complex is often administered over an extended period (usually over 2 to 6 hours) to minimize the risk of infusion-related reactions. However, if the prescription specifies an intermittent IV bolus, the nurse should follow the prescribed administration route and rate.
C. Prime the tubing with 0.9% sodium chloride (Correct Answer): Amphotericin B lipid complex can interact with dextrose-containing solutions, leading to the formation of a precipitate. Therefore, it is recommended to prime the IV tubing with 0.9% sodium chloride before administering the medication to prevent any potential interaction.
D. Use a gravity flow set: The choice of infusion set may depend on the specific institutional policies and the patient's condition. However, using a pump or a controlled infusion device is often recommended when administering medications like amphotericin B to ensure accurate infusion rates and reduce the risk of adverse reactions.

A. Hypomagnesemia B. Hypokalemia C. Hyponatremia D. Нуросаlcemia

Correct Answer is C

Explanation

A. Hypomagnesemia: While exercise can cause some magnesium loss through sweat, lithium is not specifically associated with magnesium imbalance. The primary concern in this scenario is related to sodium levels due to the impact of both exercise and lithium.
B. Hypokalemia: Exercise might also lead to potassium loss through sweat. However, potassium levels are not specifically affected by lithium in the same way as sodium levels. Hyponatremia is a more significant concern in this context.
C. Hyponatremia: Exercise-induced sodium loss compounded with lithium's potential to disrupt sodium balance increases the risk of hyponatremia. It's essential to monitor sodium levels in individuals on lithium who start new exercise programs.
D. Hypocalcemia: Exercise itself doesn't directly lead to significant calcium imbalances. Additionally, lithium is not associated with disturbances in calcium levels to the extent that it is with sodium levels.

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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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