A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?

Aspirate before injecting the medication

Use a 25-gauge, 1/2-inch needle to administer the medication

Administer the medications within 2 cm (1 in) of the umbilicus

Massage the site after injecting the medication.

Answer and Explanation

The Correct Answer is B

A. Aspirate before injecting the medication. Aspirating before injecting heparin is not recommended because it can cause tissue trauma and increase the risk of hematoma formation. Heparin is administered into the subcutaneous tissue, which has fewer blood vessels than intramuscular tissue, making aspiration unnecessary. Aspiration can also lead to bruising and discomfort, which should be minimized when administering anticoagulants.

B. Use a 25-gauge, 1/2-inch needle to administer the medication. Heparin should be administered using a small-gauge (25- to 27-gauge) needle with a length of 1/2 to 5/8 inch to reduce tissue trauma and minimize the risk of bleeding. The small needle size helps ensure that the medication is delivered into the subcutaneous tissue rather than deeper layers. Proper needle selection is important to prevent bruising and irritation, which are common concerns when administering anticoagulants.

C. Administer the medication within 2 cm (1 in) of the umbilicus. Heparin should not be injected near the umbilicus because this area has a higher density of blood vessels and an increased risk of bruising. The preferred injection sites are the abdomen (at least 5 cm or 2 inches away from the umbilicus), the upper outer thigh, or the outer upper arm. Injecting in these areas ensures proper absorption while minimizing complications such as hematoma formation.

D. Massage the site after injecting the medication. Massaging the injection site after administering heparin is contraindicated because it can lead to increased bruising, tissue irritation, and the potential for excessive bleeding. Instead of massaging, gentle pressure can be applied with a gauze pad if necessary to control minor bleeding. Clients should be advised to avoid rubbing or applying unnecessary pressure to the injection site to reduce the risk of local complications.

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Correct Answer is B

Explanation

A. "I can discontinue this medication after one negative sputum culture." Treatment for tuberculosis requires a long-term regimen lasting at least 6 months, even if the sputum culture becomes negative. Discontinuing rifampin too early increases the risk of drug resistance and treatment failure. The client must continue therapy as prescribed and complete the full course.

B. "I should take this medication on an empty stomach." Rifampin should be taken on an empty stomach (1 hour before or 2 hours after meals) to improve absorption and effectiveness. Food can reduce the bioavailability of the drug, making it less effective in treating tuberculosis. If gastrointestinal discomfort occurs, the client should consult their provider before making adjustments.

C. "I should expect to have ringing in my ears." Tinnitus (ringing in the ears) is not a common side effect of rifampin. Ototoxicity is more commonly associated with aminoglycosides (e.g., streptomycin) or vancomycin. Rifampin’s notable side effects include hepatotoxicity, red-orange discoloration of body fluids, and gastrointestinal disturbances.

D. "I can expect to have joint pain." While rifampin can cause mild flu-like symptoms, including fatigue and muscle aches, persistent joint pain is not a typical side effect. If joint pain occurs, it may be related to another condition, such as drug-induced hepatotoxicity or an adverse reaction to other tuberculosis medications (e.g., pyrazinamide, which can cause gout-like symptoms).

A. Hemoglobin levels B. Iron levels C. Platelet count D. White blood cell count

Correct Answer is A

Explanation

A. Hemoglobin levels. Epoetin alfa stimulates erythropoiesis (red blood cell production) in clients with chronic renal failure, where natural erythropoietin production is impaired. The therapeutic effect of epoetin alfa is measured by monitoring hemoglobin (Hgb) levels to ensure adequate response without exceeding safe limits. Target Hgb levels should not exceed 11 g/dL, as higher levels increase the risk of thromboembolic events and hypertension.

B. Iron levels. While iron is necessary for red blood cell production, epoetin alfa does not directly affect iron levels. However, iron supplementation may be required if iron deficiency is present, as inadequate iron stores can limit the effectiveness of epoetin alfa therapy.

C. Platelet count. Epoetin alfa primarily affects red blood cell production and has no direct effect on platelet levels. Although polycythemia (excess red blood cells) can increase the risk of clot formation, platelet count is not the primary indicator of epoetin alfa’s therapeutic effects.

D. White blood cell count. Epoetin alfa does not impact white blood cell (WBC) production. Leukocyte production is regulated by different growth factors, and WBC monitoring is more relevant for conditions such as infections, chemotherapy-induced neutropenia, or bone marrow disorders.

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Body System	Findings
Vital Signs/General History	Temperature 36.4° C (97.6° F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74mm Hg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client varicose veins.
Cardiovascular/ Respiratory	S1 S2 auscultated. No murmurs. All peripheral pulses 2+ Lung sounds clear bilaterally
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odourless. Last menstrual period was 3 months ago
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities

A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has tuberculosis and a prescription for rifampin. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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