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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Albumin is a protein that helps maintain fluid balance in the body by drawing water into the blood vessels. Albumin infusion can increase the blood volume and blood pressure in patients who are in shock due to fluid loss or sepsis.
Choice A is wrong because albumin infusion does not decrease protein levels in the body.
Albumin is a protein itself and adding it to the blood increases the protein concentration.
Choice C is wrong because oxygen saturation of 96% is normal and does not indicate any improvement or deterioration in the patient’s condition.
Choice D is wrong because PaCO2 of 30 mm Hg is low and indicates respiratory alkalosis, which can be caused by hyperventilation, fever, or anxiety. Albumin infusion does not affect PaCO2 levels directly.
Correct Answer is A
Explanation
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
One of the signs of fluid volume deficit is oliguria, which means low urine output.
Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.
Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
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