A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

Use an 18-gauge, 1-inch needle to administer the medication.

Inject 5.1 cm (2 in) away from the umbilicus.

Expel air bubble before injecting medication.

Massage the injection site after withdrawing the needle.

Answer and Explanation

The Correct Answer is B

A. Use an 18-gauge, 1-inch needle to administer the medication. An 18-gauge needle is too large for subcutaneous heparin injections, which require a smaller, finer needle, typically 25- to 27-gauge and ⅜- to ⅝-inch in length. The smaller gauge reduces discomfort and is appropriate for subcutaneous tissue.

B. Inject 5.1 cm (2 in) away from the umbilicus. Heparin injections should be given at least 2 inches from the umbilicus to avoid areas with dense blood vessels, which decreases the risk of hematoma formation and improves medication absorption.

C. Expel air bubble before injecting medication. For prefilled heparin syringes, the small air bubble should not be expelled, as it helps ensure the full dose is administered and can reduce bruising by sealing the medication in the tissue.

D. Massage the injection site after withdrawing the needle. Massaging the site after a heparin injection is not recommended as it increases the risk of bruising and tissue irritation. Instead, gentle pressure may be applied briefly if there is bleeding at the site.

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Correct Answer is B

Explanation

A. Administer the PN and fat emulsion separately:

Administering the PN and fat emulsion separately is not a typical practice. Usually, PN formulations are prepared to include both macronutrients (carbohydrates and fat) in a single bag to provide a balanced nutritional profile. Administering them separately might lead to inconsistencies in the client's nutritional intake.

B. Prepare the client for a central venous line:

This is the correct action. Parenteral nutrition (PN) with a high concentration of dextrose (20%) and fat emulsions can be hypertonic and irritating to peripheral veins. Therefore, a central venous line is often recommended for the administration of such solutions. Preparing the client for a central venous line helps ensure the safe and effective delivery of PN.

C. Change the PN infusion bag every 48 hr:

The frequency of changing the PN infusion bag is not solely determined by time but rather by factors such as the stability of the solution, risk of contamination, and compatibility of the components. The specific recommendation for changing the PN bag should be based on institutional policies and the characteristics of the PN solution being used.

D. Obtain a random blood glucose daily:

While monitoring blood glucose is important in clients receiving PN, obtaining a random blood glucose daily is not specific enough for managing the potential hyperglycemic effects of a 20% dextrose solution. Continuous glucose monitoring or more frequent and scheduled blood glucose checks may be necessary.

A. Ensure the client's heels are not touching the mattress. B. Massage the client's bony prominences. C. Raise the head of the client's bed to a 60° angle. D. Reposition the client every 4 hr.

Correct Answer is A

Explanation

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

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A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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