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.
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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Related Questions
Correct Answer is D
Explanation
A. The nurse's empathy about the client having to self-inject:
While empathy is important for building a therapeutic relationship, the client's motivation to learn is more likely to be influenced by factors directly related to their own needs and perceived benefits.
B. The client seeking family approval by agreeing to a teaching plan:
External factors, such as seeking family approval, may influence a client's willingness to participate in a teaching plan, but they might not be as effective in sustaining motivation over the long term. Intrinsic motivation tends to be more enduring and impactful.
C. The nurse explaining the need for education to the client:
While explaining the need for education is important, the client's motivation may be more influenced by their personal beliefs about the benefits of learning and meeting their own needs rather than an external explanation.
D. The client's belief that his needs will be met through education:
This statement reflects the client's intrinsic motivation, where the client perceives that learning to self-administer daily low-dose heparin injections will meet his needs. Intrinsic motivation is a powerful driver for learning because it comes from within the individual.
Correct Answer is A
Explanation
A. Ask the family if they wish to assist in washing the client's body:
This is an appropriate action. Providing an opportunity for the family to participate in postmortem care can be a culturally sensitive and therapeutic approach. It allows the family to be involved in a meaningful way and may contribute to the grieving process.
B. Turn overhead lights to a bright setting:
This is incorrect. The environment for postmortem care should be handled with respect and consideration for the family. Turning the lights to a bright setting may create an uncomfortable or clinical atmosphere. A calm and serene environment is more appropriate for this sensitive task.
C. Leave the client's eyes open until the family views the body:
This is incorrect. It is customary to gently close the deceased person's eyes as part of postmortem care. Leaving the eyes open may be distressing for the family and does not contribute to creating a peaceful appearance.
D. Remove the client's dentures for their family to keep:
This is incorrect. Dentures are typically returned to the family rather than kept by the family. The nurse should handle the removal of any personal items with sensitivity and respect, returning them to the family as appropriate.
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