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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. For assessing pain in a 4-year-old child following an orthopedic procedure, the nurse should use the FACES pain scale.
The FACES pain scale uses a series of faces with varying expressions, from smiling to crying, to help children express their level of pain. Children are asked to point to the face that best matches how they feel. This scale is particularly useful for young children who may not have the verbal skills to describe their pain accurately using words or numbers.
B. Word-graphic
Explanation: The word-graphic pain scale typically uses a combination of words and drawings to assess pain, making it more suitable for children who are slightly older and can understand simple words and concepts.
C. Numeric
Explanation: The numeric pain scale involves asking the child to rate their pain on a scale from 0 to 10. This scale is more appropriate for older children who can understand and assign numerical values to their pain intensity.
D. CRIES
Explanation: The CRIES pain scale is often used for assessing pain in newborns and infants up to 6 months old. It focuses on crying, oxygen saturation, vital signs, and facial expressions.
Correct Answer is D
Explanation
A. Orthostatic hypotension refers to a drop in blood pressure upon standing up quickly. This is not a commonly associated adverse effect of pioglitazone.
B. Tinnitus refers to ringing in the ears and is not typically related to pioglitazone use.
C. Insomnia (difficulty sleeping) is not commonly reported as an adverse effect of pioglitazone.
D. Fluid retention
The nurse should plan to monitor the client for the adverse effects of fluid retention.
Pioglitazone is an oral antidiabetic medication that belongs to the thiazolidinedione class. One of the common adverse effects of pioglitazone is fluid retention or edema. This occurs due to its mechanism of action which can cause fluid buildup in the body's tissues, particularly in the lower extremities. Clients taking pioglitazone should be monitored for signs of edema, such as swelling in the ankles, legs, or feet. Monitoring for weight gain and any signs of worsening heart failure is also important.
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