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 A
Explanation
Choice A reason: Bleeding gums is a possible adverse effect of taking gingko biloba, as it may increase the risk of bleeding by inhibiting platelet aggregation and interfering with clotting factors. Gingko biloba may also interact with other medications that affect bleeding, such as anticoagulants, antiplatelets, or NSAIDs. The nurse should advise the client to monitor for signs of bleeding, such as bruising, nosebleeds, or hematuria, and report them to the provider.
Choice B reason: Decreased alertness is not a likely adverse effect of taking gingko biloba, as it may have the opposite effect of enhancing cognitive function and memory. Gingko biloba may improve blood flow to the brain and protect against oxidative stress and neuronal damage. The nurse should inform the client that gingko biloba may take several weeks to show its benefits and that the evidence for its effectiveness is inconclusive.
Choice C reason: Breast enlargement is not a known adverse effect of taking gingko biloba, as it does not affect the hormonal levels or the breast tissue. Gingko biloba may have some estrogenic activity, but it is not significant enough to cause gynecomastia or breast tenderness. The nurse should assess the client for other possible causes of breast enlargement, such as medications, liver disease, or tumors.
Choice D reason: Bad breath is not a common adverse effect of taking gingko biloba, as it does not affect the oral hygiene or the digestive system. Gingko biloba may have a mild odor, but it is not unpleasant or persistent. The nurse should advise the client to maintain good oral care and to check for other possible causes of bad breath, such as infections, dental problems, or dietary factors.
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.
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