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 ["125"]
Explanation
To calculate the rate at which the IV pump should be set to deliver the prescribed volume of intravenous fluids,
Divide the total volume of fluids (3,000 mL) by the number of hours over which they are to be administered (24 hours). This calculation gives you 125 mL/hr.
Therefore, the nurse should set the IV pump to deliver 125 mL of fluid per hour to meet the 24-hour requirement.
Correct Answer is A
Explanation
A. Infiltration occurs when IV fluid or medication leaks into the surrounding tissues rather than entering the vein. Coolness, blanching (pale appearance), swelling, and discomfort at the IV site are common signs of infiltration.
B. Local inflammation at the IV site can occur due to irritation or infection. Redness, warmth, swelling, tenderness, and possibly purulent drainage (pus) are typical signs. The description of a cool and blanched IV site does not fit the typical signs of inflammation, which usually involve warmth and redness.
C. Thrombophlebitis is inflammation of a vein with associated blood clot formation. Pain, warmth, redness, and swelling along the path of the vein are common. Thrombophlebitis typically presents with warmth and redness at the site, whereas the cool and blanched appearance described by the student suggests fluid infiltration rather than a thrombus causing inflammation.
D. Phlebitis is inflammation of the vein itself. Pain, redness, warmth, and swelling directly over the vein. Phlebitis usually manifests with warmth and redness, which are not present in the described symptoms.
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