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 D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is B
Explanation
B. Before administering any medication, especially antibiotics like amoxicillin, the nurse must assess the patient for allergies or previous adverse reactions to amoxicillin or other beta-lactam antibiotics. Allergic reactions can range from mild rashes to severe anaphylactic reactions, so it's essential to confirm the
patient's allergy status and assess for any signs or symptoms of allergic reaction before proceeding with administration.
A. Flushing the IV site with normal saline is typically not required specifically before administering IV amoxicillin unless it is part of the institution's standard practice to flush all IV lines before and after medication administration.
C. While monitoring intake and output (I&O) is important for assessing fluid balance and kidney function, it is not directly necessary before administering IV amoxicillin unless there are specific concerns related to the patient's fluid status or renal function. However, it is good practice to have a general understanding of the patient's recent fluid intake and output patterns.
D. Creatinine clearance is a measure of kidney function. Checking the latest creatinine clearance result is important for assessing renal function, especially before administering medications excreted by the kidneys. However, amoxicillin is primarily excreted by the kidneys in its unchanged form, so knowing the patient's renal function status can help in determining the appropriate dosage or adjusting the dosing interval if necessary.
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