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
The Correct answer is A.
Choice A reason: Evaluating the client for nausea, vomiting, and anorexia is important because these are common signs of digoxin toxicity. Digoxin is a cardiac glycoside used to treat heart failure and certain arrhythmias, but it has a narrow therapeutic window. Toxicity can occur due to various factors, including renal insufficiency or drug interactions. Monitoring gastrointestinal symptoms like nausea, vomiting, and loss of appetite can help detect toxicity early.
Choice B reason: Withholding digoxin if the heart rate is above 100/min is not typically recommended. Digoxin has a negative chronotropic effect, meaning it can decrease heart rate. However, the decision to withhold medication usually depends on a heart rate that is too low (bradycardia), not high. The normal range for resting heart rate in adults is 60-100 beats per minute. Therefore, withholding digoxin for a heart rate above 100/min without other clinical justifications would not be appropriate.
Choice C reason: Measuring the apical pulse rate for 30 seconds before administration is not the standard practice. The apical pulse should be measured for a full minute to ensure accuracy, especially in clients with heart failure who are receiving digoxin. This is because digoxin can cause arrhythmias, and a shorter measurement period may not provide a true representation of the heart's rhythm.
Choice D reason: Instructing the client to eat foods that are low in potassium is incorrect. Clients taking digoxin should maintain a normal potassium level, as hypokalemia can increase the risk of digoxin toxicity. The normal serum potassium level is 3.5-5.0 mEq/L. Foods high in potassium can help maintain this balance and should not be avoided unless there is a specific clinical indication, such as hyperkalemia.
Correct Answer is D
Explanation
Choice A reason: "Place one tablet under your tongue every 5 minutes for 30 minutes to relieve chest pain." is not the correct statement. This is an incorrect and potentially dangerous instruction, as it can cause overdose and severe hypotension. The nurse should instruct the client to place one tablet under the tongue at the first sign of chest pain, and repeat every 5 minutes for up to three doses, if needed. The client should call 911 if the pain is not relieved after the first dose.
Choice B reason: "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." is not the correct statement. This is a false and misleading explanation of how nitroglycerin works. Nitroglycerin does not dissolve blood clots, nor does it affect the occlusion of the arteries. Nitroglycerin is a vasodilator that relaxes the smooth muscle of the blood vessels, especially the veins. This reduces the preload and the oxygen demand of the heart, and relieves the chest pain caused by ischemia.
Choice C reason: "You can store the bottle of tablets in your bathroom medicine cabinet." is not the correct statement. This is an inappropriate and unsafe storage recommendation, as it can affect the potency and effectiveness of the medication. The nurse should instruct the client to store the bottle of tablets in a cool, dry, and dark place, away from heat, moisture, and light. The client should also keep the bottle tightly closed and replace it every 6 months, or as directed by the provider.
Choice D reason: "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." is the correct statement. This is a simple and accurate description of how nitroglycerin helps to relieve anginal pain. Nitroglycerin dilates the coronary arteries, which supply blood and oxygen to the heart muscle. This improves the blood flow and oxygen delivery to the ischemic areas of the heart, and reduces the pain and discomfort.
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