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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. The nurse should promptly notify the healthcare provider to discuss the allergy history and request an alternative antibiotic that is not structurally related to penicillin or cephalosporins. Examples of alternative antibiotics may include antibiotics from different classes such as macrolides or fluoroquinolones, depending on the indication and sensitivity profile.

A. Diphenhydramine (Benadryl) is an antihistamine that can help manage allergic reactions. However, it should not be used as a standalone precautionary measure for a client with a history of anaphylaxis to penicillin. Anaphylaxis is a severe allergic reaction that can lead to life-threatening symptoms such as difficulty breathing, swelling, and low blood pressure.

B. Before taking any further steps, the nurse should clarify and confirm the nature and severity of the client's allergic reaction to penicillin. Anaphylaxis is a serious allergic reaction characterized by rapid onset and potentially life-threatening symptoms. Clarifying the history ensures accurate decision- making regarding the administration of cephalexin.

C. This is not recommended without further clarification and assessment. Given the history of anaphylaxis to penicillin, there is a significant risk of cross-reactivity with cephalosporins like cephalexin. Cephalosporins have a structural similarity to penicillin and can provoke allergic reactions in individuals with penicillin allergy, including anaphylaxis.

A. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. B. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. C. Find the center of the anterior aspect of the thigh. D. Locate the center of the arm between the elbow and the shoulder.

Correct Answer is B

Explanation

B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.

A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.

C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.

D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Correct Answer is B

Explanation

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

A 22-year-old dialysis patient presents to the ER with chest pain and palpitations. Laboratory tests reveal a Potassium (K+) level of 7.0 mEq/L. Which electrolyte imbalance is the patient suffering from?

A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

A nurse is assisting in the plan of care for a client who has hypernatremia. Which of the following IV solutions should the nurse plan to initiate?

A nurse is caring for a client who is receiving a continuous IV infusion through a short-peripheral device. Which of the following actions should the nurse take?

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

A nurse is preparing an injection using a single dose glass ampule. Which of the following actions should the nurse take?