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 D
Explanation
A. "Keep the tablets at room temperature in their original glass bottle." This is a correct storage instruction. Nitroglycerin tablets are sensitive to heat and light, so they should be stored in their original container, protected from light, and kept at room temperature.
B. "Discard any tablets you do not use every 6 months." This is not an accurate instruction. Nitroglycerin tablets usually have an expiration date printed on the label, and they should be discarded after that date.
C. "Take one tablet each morning 30 minutes prior to eating." This is not an accurate instruction. Sublingual nitroglycerin is taken as needed to relieve angina symptoms, not on a regular schedule like a daily medication.
D. "Place the tablet between your cheek and gum to dissolve."
Sublingual nitroglycerin tablets are used to relieve angina symptoms by causing vasodilation, which increases blood flow to the heart muscle. To take sublingual nitroglycerin tablets effectively, the client should be instructed to place the tablet between the cheek and gum to dissolve. This allows the medication to be absorbed through the mucous membranes in the mouth and enter the bloodstream quickly, providing rapid relief from angina symptoms.
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.

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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
