A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?
Insert the needle at a 15-degree angle.
Aspirate for blood return before administration.
Administer the medication into the abdomen.
Massage the site after the injection.
The Correct Answer is C
Choice A rationale
Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.
Choice B rationale
Aspirating for blood return before administration is not necessary when administering heparin.
Choice C rationale
Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.
Choice D rationale
Massaging the site after the injection is not recommended as it can cause bruising.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,D,B
Explanation
Choice A rationale
Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice B rationale
Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.
Choice C rationale
Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.
Choice D rationale
Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.
Correct Answer is B
Explanation
Choice A rationale
This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.
Choice B rationale
This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.
Choice C rationale
This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.
Choice D rationale
This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.
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