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.
Massage the site after administering the medication.
Use a 21-gauge needle for the injection.
Aspirate before injecting the medication.
The Correct Answer is A
This is because the umbilicus is a potential site of infection and should be avoided when administering subcutaneous heparin.
Choice B is wrong because massaging the site after administering the medication can cause bruising and hematoma formation.
Choice C is wrong because a 21-gauge needle is too large for subcutaneous injection and can cause tissue trauma and bleeding.
A smaller needle, such as 25- or 27-gauge, should be used.
Choice D is wrong because aspirating before injecting the medication can increase the risk of hematoma formation and is not recommended for subcutaneous heparin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyponatremia is a condition where the sodium level in the blood is too low, which can cause confusion, lethargy, seizures, and coma. A hypertonic solution is a fluid that has a higher concentration of solutes than the blood, which can help raise the sodium level and reduce the brain swelling caused by hyponatremia. Therefore, improved cognition indicates that the treatment is effective.
Choice B. Cardiac arrhythmias absent.
Cardiac arrhythmias are not a common symptom of hyponatremia unless it is severe or rapid in onset.
Therefore, their absence does not necessarily indicate that the treatment is effective.
Choice C. Decreased vomiting.
Vomiting can be a cause or a consequence of hyponatremia, depending on the underlying condition.
Decreased vomiting may indicate that the patient is less nauseated, but it does not reflect the sodium level or the brain status.
Choice D. Absent Chvostek’s sign.
Chvostek’s sign is a facial twitching that occurs when tapping on the cheek, which indicates hypocalcemia (low calcium level).
It is not related to hyponatremia or hypertonic solution.
Normal ranges for sodium are 135 to 145 mEq/L and for calcium are 8.5 to 10.5 mg/dL.
Correct Answer is B
Explanation
Choice A rationale:
The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.
Choice B rationale:
After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.
Choice C rationale:
The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.
Choice D rationale:
Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.
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