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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Acetaminophen is contraindicated in patients with severe hepatic impairment or severe active liver disease1 and should be used with caution in patients with hepatic impairment or active liver disease. Alcohol use disorder can cause liver damage and increase the risk of acetaminophen toxicity.

Choice A is wrong because hepatitis B vaccine within the last week is not a contraindication for receiving acetaminophen.

There is no evidence that acetaminophen interferes with the immune response to the vaccine or causes adverse effects.

Choice B is wrong because chronic kidney disease is not a contraindication for receiving acetaminophen.

Acetaminophen is mainly metabolized by the liver and has minimal renal excretion.

However, patients with chronic kidney disease should consult their doctor before taking acetaminophen as they may have other conditions that affect its use.

Choice C is wrong because diabetes mellitus is not a contraindication for receiving acetaminophen.

Acetaminophen does not affect blood glucose levels or interact with oral antidiabetic drugs.

However, patients with diabetes mellitus should consult their doctor before taking acetaminophen as they may have other conditions that affect its use.

A. Sodium 142 mEq/L. B. BUN 16 mg/dL. C. Potassium 5.3 mEq/L. D. Albumin 4 g/dL.

Correct Answer is C

Explanation

This is a high level of potassium in the blood (the normal range is 3.5 to 5 mEq/L) and can be dangerous for the heart.

Triamterene is a potassium-sparing diuretic that prevents the body from losing too much potassium in the urine. It can cause hyperkalemia (high potassium), especially in people with kidney disease, diabetes, or severe illness. The nurse should check the potassium level before giving triamterene and hold the medication if it is above 5 mEq/L.

The other choices are incorrect because:

Choice A: Sodium 142 mEq/L.

This is a normal level of sodium in the blood (the normal range is 135 to 145 mEq/L) and does not require withholding triamterene. Triamterene can cause hyponatremia (low sodium) by increasing the excretion of sodium in the urine. The nurse should monitor the sodium level during triamterene therapy and report any signs of low sodium such as confusion, weakness, or seizures.

Choice B: BUN 16 mg/dL.

This is a normal level of blood urea nitrogen (BUN) in the blood (normal range is 7 to 20 mg/dL) and does not require withholding

triamterene. BUN is a measure of kidney function and can be elevated in kidney disease or dehydration. Triamterene can cause an increase in BUN by reducing the blood flow to the kidneys or by interacting with other medications that affect the kidneys. The nurse should monitor the BUN level during triamterene therapy and report any signs of kidney impairment such as decreased urine output, swelling, or nausea. •

Choice D: Albumin 4 g/dL.

This is a normal level of albumin in the blood (the normal range is 3.4 to 5.4 g/dL) and does not require withholding triamterene. Albumin is a protein that helps maintain fluid balance and transport substances in the blood. Triamterene does not affect albumin levels directly, but it can cause fluid loss or retention that may alter albumin levels indirectly. The nurse should monitor the albumin level during triamterene therapy and report any signs of fluid imbalance such as weight changes, edema, or shortness of breath.

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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

A nurse is reviewing the medical record of an adult client who has a fever and a prescription for acetaminophen. Which of the following findings should the nurse identify as a contraindication for receiving this medication?

Correct Answer is D

Explanation

A nurse is caring for a client who is taking triamterene. For which of the following laboratory values should the nurse withhold the medication?

Correct Answer is C

Explanation

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A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?

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