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 B
Explanation
Choice A reason: Ataxia is not a manifestation of digoxin toxicity, as it does not affect the coordination or balance of the client. Ataxia may be caused by other factors, such as cerebellar disorders, alcohol intoxication, or medication interactions.
Choice B reason: Anorexia is a manifestation of digoxin toxicity, as it affects the appetite and digestion of the client. Anorexia may be accompanied by nausea, vomiting, or abdominal pain, which are also signs of digoxin toxicity. Anorexia may lead to weight loss, dehydration, or electrolyte imbalance, which can worsen the condition of the client.
Choice C reason: Photosensitivity is not a manifestation of digoxin toxicity, as it does not affect the skin or the eyes of the client. Photosensitivity may be caused by other factors, such as sun exposure, allergies, or medication interactions.
Choice D reason: Jaundice is not a manifestation of digoxin toxicity, as it does not affect the liver or the bilirubin level of the client. Jaundice may be caused by other factors, such as liver disease, gallstones, or hemolysis.
Correct Answer is C
Explanation
Choice A reason: "I'll be sure to eat more foods with vitamin K." is not the correct statement. Vitamin K is a nutrient that helps the blood to clot. Warfarin is an anticoagulant that inhibits the action of vitamin K and prevents the formation of blood clots. Eating more foods with vitamin K can counteract the effect of warfarin and increase the risk of thrombosis. The client should maintain a consistent intake of vitamin K and avoid sudden changes in their diet.
Choice B reason: "I'll take aspirin for my headaches." is not the correct statement. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and prolongs bleeding time. Taking aspirin with warfarin can increase the risk of bleeding and bruising. The client should avoid taking any NSAIDs without consulting their provider. The client should use acetaminophen or other non-NSAID pain relievers for their headaches.
Choice C reason: "I'll use my electric razor for shaving." is the correct statement. Using an electric razor for shaving can reduce the risk of cuts and bleeding. The client should avoid using sharp objects or instruments that can cause injury or trauma. The client should also use a soft toothbrush and floss gently to prevent bleeding gums.
Choice D reason: "It's okay to have a couple of glasses of wine with dinner each evening." is not the correct statement. Alcohol can interact with warfarin and affect its metabolism and effectiveness. Drinking alcohol with warfarin can either increase or decrease the blood levels of warfarin and alter the international normalized ratio (INR), which is a measure of the blood's clotting ability. The client should limit their alcohol intake and monitor their INR regularly.
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