A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?
Inject the medication into the abdomen above the level of the iliac crest.
Massage the injection site after administration of the medication.
Use a 1-inch needle to inject the medication.
Use a 22-gauge needle to inject the medication.
The Correct Answer is A
Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is the correct action. This is the preferred site for heparin administration, as it has fewer blood vessels and nerves, and allows for better absorption of the medication. The nurse should avoid the area around the umbilicus, as it may have increased bleeding and bruising.
Choice B reason: Massaging the injection site after administration of the medication is not the correct action. This may cause hematoma formation, tissue irritation, and reduced effectiveness of the medication. The nurse should apply gentle pressure to the injection site for 1 to 2 minutes after administration.
Choice C reason: Using a 1-inch needle to inject the medication is not the correct action. This may cause pain, tissue damage, and bleeding. The nurse should use a 25- to 28-gauge needle that is 3/8 to 5/8 inch long to inject the medication.
Choice D reason: Using a 22-gauge needle to inject the medication is not the correct action. This may cause pain, tissue damage, and bleeding. The nurse should use a 25- to 28-gauge needle that is 3/8 to 5/8 inch long to inject the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Platelets 190,000/mm3 is within the normal range of 150,000 to 450,000/mm3. This result does not indicate a bleeding risk or a need to adjust the warfarin dose.
Choice B reason: Hct 44% is within the normal range of 37% to 47% for females and 42% to 52% for males. This result does not indicate anemia or polycythemia, which could affect the warfarin therapy.
Choice C reason: PT 45 seconds is above the normal range of 11 to 13.5 seconds. This result indicates that the blood is taking too long to clot, which increases the risk of bleeding. The nurse should notify the provider and expect a decrease in the warfarin dose.
Choice D reason: Hgb 16 g/dL is within the normal range of 12 to 16 g/dL for females and 14 to 18 g/dL for males. This result does not indicate anemia or polycythemia, which could affect the warfarin therapy.
Correct Answer is A
Explanation
Choice A reason: Infection is the correct condition that the client is at increased risk for. Agranulocytosis is a severe decrease in the number of granulocytes, which are a type of white blood cell that fight infection. Propylthiouracil is an antithyroid drug that can cause agranulocytosis as a rare but serious side effect. The client with agranulocytosis is more susceptible to bacterial and fungal infections, and may present with fever, sore throat, mouth ulcers, and skin lesions.
Choice B reason: Excessive bleeding is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the platelets, which are the blood cells that help with clotting. Propylthiouracil does not cause bleeding disorders, although it may interact with anticoagulants and increase their effect.
Choice C reason: Hyperglycemia is not the correct condition that the client is at increased risk for. Agranulocytosis does not affect the insulin, which is the hormone that regulates blood glucose levels. Propylthiouracil does not cause hyperglycemia, although it may interfere with the metabolism of oral hypoglycemic agents and decrease their effect.
Choice D reason: Ecchymosis is not the correct condition that the client is at increased risk for. Ecchymosis is a bruise caused by bleeding under the skin. Agranulocytosis does not cause ecchymosis, as it does not affect the blood vessels or the platelets. Propylthiouracil does not cause ecchymosis, although it may increase the risk of skin rash and pruritus.
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