A nurse is preparing to administer heparin subcutaneously to an obese client who has a deep vein thrombosis. Which of the following actions should the nurse take?
Select a 22-gauge needle for heparin administration.
Insert the needle at a 90° angle.
Massage the injection site after administering the heparin.
Aspirate for a blood return prior to injecting the heparin.
The Correct Answer is B
B. Subcutaneous injections are generally administered at a 45° or 90° angle, depending on the amount of subcutaneous tissue present. In obese clients, there is typically more subcutaneous tissue, so inserting the needle at a 90° angle may be necessary to ensure proper medication absorption.
A. A smaller gauge needle (such as 25 or 26 gauge) is usually more appropriate for subcutaneous injections to minimize discomfort and tissue trauma, especially in obese clients where there is more subcutaneous tissue.
C. Massaging the injection site after administering heparin is not recommended. It can cause discomfort, bruising, and potentially alter the absorption rate of the medication. The injection site should be gently
pressed with a dry gauze pad after withdrawal of the needle to help disperse the medication and prevent leakage, but massaging should be avoided.
D. Aspiration is not necessary for subcutaneous injections. It is generally used for intramuscular injections to ensure the needle is not in a blood vessel, which is less of a concern for subcutaneous injections. The injection technique involves pinching the skin and injecting the medication into the subcutaneous tissue without aspirating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.
A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.
C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.
D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.
Correct Answer is A
Explanation
A. 0.9% sodium chloride (normal saline) is isotonic, meaning it has the same concentration of solutes as blood plasma. It is used to expand intravascular volume and replace fluids and electrolytes.
B. "Hypnotic" refers to medications that induce sleep and has no relevance to IV solutions. This term does not apply to IV solutions.
C. A hypotonic solution has a lower concentration of solutes compared to normal body fluids. Examples include 0.45% sodium chloride (half-normal saline) or 5% dextrose in water (D5W). 0.9% sodium chloride (normal saline) is not hypotonic; rather, it is isotonic.
D. A hypertonic solution has a higher concentration of solutes compared to normal body fluids. Examples include 3% sodium chloride or 5% dextrose in 0.9% sodium chloride. 0.9% sodium chloride (normal saline) is not hypertonic; rather, it is isotonic.
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