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: Hematocrit 45% is not the correct data. Hematocrit is the percentage of red blood cells in the blood. The normal range for hematocrit is 37% to 47% for women and 42% to 52% for men. Hematocrit 45% is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or destruction of red blood cells.
Choice B reason: Platelets 74,000/mm3 is the correct data. Platelets are the blood cells that are responsible for clotting and preventing bleeding. The normal range for platelets is 150,000 to 400,000/mm3. Platelets 74,000/mm3 is below the normal range and indicates thrombocytopenia, which is a low platelet count. Thrombocytopenia is a serious complication of heparin therapy that can cause bleeding, bruising, and petechiae. The nurse should report this finding to the provider immediately and stop the heparin infusion.
Choice C reason: Partial thromboplastin time (PTT) 65 seconds is not the correct data. PTT is a blood test that measures the time it takes for the blood to clot. The normal range for PTT is 25 to 35 seconds. PTT 65 seconds is above the normal range and indicates that the blood is taking longer to clot. This is an expected effect of heparin therapy, as heparin is an anticoagulant that inhibits the formation of blood clots. The nurse should monitor the PTT and adjust the heparin dose according to the provider's orders and the protocol.
Choice D reason: White blood cell count 8,000/mm3 is not the correct data. White blood cells are the blood cells that are involved in the immune system and fight infections. The normal range for white blood cells is 4,500 to 11,000/mm3. White blood cell count 8,000/mm3 is within the normal range and does not indicate any abnormality related to heparin therapy. Heparin does not affect the production or function of white blood cells.
Correct Answer is C
Explanation
Choice A reason: Black cohosh is an herbal supplement that is used to treat menopausal symptoms, such as hot flashes and mood swings. It does not have a significant interaction with warfarin and does not affect the coagulation status of the client.
Choice B reason: Echinacea is an herbal supplement that is used to boost the immune system and prevent or treat common colds and infections. It does not have a significant interaction with warfarin and does not affect the coagulation status of the client.
Choice C reason: Feverfew is an herbal supplement that is used to treat migraines, arthritis, and fever. It has a significant interaction with warfarin and can increase the risk of bleeding and bruising. It can also reduce the effectiveness of warfarin and alter the client's international normalized ratio (INR).
Choice D reason: Flaxseed is an herbal supplement that is used to lower cholesterol, blood pressure, and inflammation. It does not have a significant interaction with warfarin and does not affect the coagulation status of the client.
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