A nurse is reinforcing teaching with a client who is to start subcutaneous heparin.
Which of the following information should the nurse include in the teaching?
Use a soft-bristled toothbrush.
Inject the medication deep into the thigh muscle.
Expect stools to become black and tarry.
Easy bruising indicates the medication is effective.
The Correct Answer is A
The nurse should include in the teaching that the client should use a soft-bristled toothbrush.
Heparin is an anticoagulant that decreases the clotting ability of the blood 1.
Using a soft-bristled toothbrush can help prevent bleeding of the gums while brushing teeth.
Choice B is incorrect because heparin should not be injected deep into the thigh muscle.
Instead, it should be given subcutaneously (under the skin) 2.
Choice C is incorrect because black and tarry stools are not an expected side effect of heparin.
Choice D is incorrect because easy bruising does not indicate that the medication is effective.
Instead, easy bruising may be a side effect of heparin and should be reported to the healthcare provider 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
NPH insulin has an onset of action of about 1 to 2 hours, peaks in 4 to 12 hours, and lasts up to 24 hours. Given the administration at 0700, the onset of action would typically occur between 0800 and 0900. Hypoglycemia is most likely to occur during the onset or peak periods due to the insulin's glucose-lowering effect.
Among the options:
- A. 0715: Too early, as NPH insulin's onset is not within 15 minutes.
- B. 0800: Within the onset window (1 hour after administration), making it a plausible time to observe for hypoglycemia.
- C. 0900: Also within the onset window (2 hours after administration), another reasonable time to monitor.
- D. 1000: Slightly beyond the typical onset but still early in the action profile, where hypoglycemia could occur if glucose levels drop.
Since the question asks for the time to observe for hypoglycemia caused by the onset, the earliest time within the onset window is most appropriate. Thus, B. 0800 is the best answer, as it aligns with the start of NPH insulin’s onset period.
Final Answer: B. 0800
Correct Answer is C
Explanation
The statement “I won’t seal my lips around the mouthpiece and take slow, deep breaths” indicates a need for further teaching.
When using a nebulizer, the client should place the mouthpiece in their mouth between their teeth and close their lips around it 1.
They should also take slow, deep breaths to ensure that the medication is properly inhaled 1.
Choice A is incorrect because washing the mouthpiece with warm soapy water each day is a recommended action 2.
Choice B is incorrect because storing the nebulizer at room temperature is acceptable.
Choice D is incorrect because it is not necessary to keep medication in the nebulizer at all times.
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