A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?

Insert the needle at least 5 cm (2 in) from the umbilicus.

Aspirate before injecting the medication.

Massage the site after administering the medication.

Use a 21-gauge needle for the injection.

Answer and Explanation

The Correct Answer is A

A. Insert the needle at least 5 cm (2 in) from the umbilicus: Correct. Subcutaneous injections, including heparin, should be given in fatty tissue away from major blood vessels and bony prominences. The recommended sites are usually the abdomen, thighs, or upper arms.
B. Aspirate before injecting the medication: Incorrect. Aspiration is not required for subcutaneous injections because they are administered into the subcutaneous fat layer, not a blood vessel. Aspiration could cause trauma and discomfort to the client.
C. Massage the site after administering the medication: Incorrect. Massaging the site after administering heparin can cause bruising or discomfort. Instead, it's recommended to apply gentle pressure with a sterile gauze pad for a few seconds.
D. Use a 21-gauge needle for the injection: Incorrect. Subcutaneous injections are typically administered with smaller gauge needles, such as 25-30 gauge, to minimize pain and tissue damage.

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Correct Answer is ["0.4 mL"]

Explanation

To calculate the volume of heparin needed, you can use the formula:

Volume (mL) = Desired dose (units) / Concentration (units/mL)

In this case, the desired dose is 4,000 units and the concentration is 10,000 units/mL.

Volume = 4,000 units / 10,000 units/mL = 0.4 mL

So, the nurse should administer 0.4 mL of heparin.

A. Apply a warm, moist compress. B. Slow the IV solution rate. C. Initiate a new IV distal to the initial site. D. Maintain the extremity below the level of the heart

Correct Answer is A

Explanation

A. Apply a warm, moist compress.
Explanation:
A cool and edematous IV infusion site could indicate infiltration of the IV site, which occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream. Applying a warm, moist compress to the site can help improve blood circulation and reduce the discomfort associated with infiltration. This action can also help reduce tissue damage.
B. Slow the IV solution rate: Slowing the IV solution rate might not be effective in resolving the infiltration. It's important to address the infiltration itself rather than just adjusting the rate of infusion.
C. Initiate a new IV distal to the initial site: While starting a new IV site might be necessary if the current site cannot be salvaged, it's not the initial action to take. Applying warm, moist compresses and assessing the severity of the infiltration are appropriate steps before considering a new IV site.
D. Maintain the extremity below the level of the heart: Elevating the extremity could help reduce swelling in some cases, but it's not the primary action to take when dealing with IV infiltration.
Remember, prompt assessment and appropriate interventions are essential to prevent complications associated with IV infiltration.

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A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.4 mL"]

Explanation

A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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