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 A

Explanation

A. Cover the administration area with plastic wrap. After applying nitroglycerin ointment, the area should be covered with plastic wrap or a transparent dressing to prevent evaporation and ensure proper absorption through the skin. This also helps prevent the medication from accidentally transferring to another person or clothing.

B. Massage the ointment into the skin. Nitroglycerin ointment should not be massaged into the skin, as this can cause rapid absorption and lead to hypotension and dizziness due to vasodilation. Instead, it should be applied as a thin, even layer and covered with a dressing.

C. Spread the ointment in a 10 cm² (4 in²) area. The correct application method involves measuring the exact prescribed amount (e.g., using the applicator paper) and applying it in a thin layer. The area of application may vary based on the dosage, but the focus should be on accurate measurement, not a specific area size.

D. Apply the ointment in a thick layer. A thick application is unnecessary and could increase absorption too quickly, leading to side effects such as headache, dizziness, and hypotension. Instead, a measured dose should be spread thinly and evenly onto clean, dry skin.

A. "This is an expected adverse effect of the medication.” B. "Stop taking the medication. You are having an allergic reaction. C. "This condition will only last a couple of days." D. "Taking the medication with red meat will cause this adverse effect."

Correct Answer is A

Explanation

A. "This is an expected adverse effect of the medication." Rifampin commonly causes red-orange discoloration of bodily fluids, including saliva, tears, urine, and sweat. This occurs due to the drug's excretion and is harmless. It does not indicate internal bleeding or organ dysfunction. Clients should be educated about this side effect in advance to prevent alarm and unnecessary discontinuation of the medication, as adherence to tuberculosis treatment is crucial.

B. "Stop taking the medication. You are having an allergic reaction." The red discoloration caused by rifampin is a known side effect, not an allergic reaction. A true allergic response would include symptoms such as rash, itching, swelling, or difficulty breathing. Stopping rifampin without medical advice could disrupt tuberculosis treatment, leading to drug resistance or treatment failure, making this an inappropriate recommendation.

C. "This condition will only last a couple of days." The discoloration of bodily fluids persists throughout the duration of rifampin therapy. Tuberculosis treatment can last several months, so the client should expect this effect to continue as long as they are taking the medication. Providing incorrect information may cause the client to worry unnecessarily when the discoloration does not resolve quickly.

D. "Taking the medication with red meat will cause this adverse effect." The discoloration is due to rifampin’s chemical properties and metabolism, not dietary intake. Red-colored foods, such as red meat or berries, do not influence this effect. Providing inaccurate dietary information may lead to unnecessary dietary restrictions, which are not needed for managing this side effect.

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