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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Social worker:
While social workers play a crucial role in addressing various aspects of a patient's well-being, such as psychosocial needs and support systems, they may not be the primary healthcare team member to address the specific issue of a client with severe rheumatoid arthritis being unable to feed herself.
B. Physician assistant:
Physician assistants are medical professionals who work under the supervision of a physician. While they contribute to the overall care of the patient, they may not be the primary specialist for addressing the functional limitations and specific needs associated with severe rheumatoid arthritis.
C. Physical therapist:
Physical therapists primarily focus on physical rehabilitation, movement, and mobility. While they may be involved in the overall care plan for a patient with rheumatoid arthritis, the specific issue of hand function and activities of daily living, such as feeding, is more directly addressed by occupational therapists.
D. Occupational therapist:
The correct choice. Occupational therapists specialize in helping individuals regain or improve their ability to perform daily activities, such as feeding, dressing, and grooming. In the case of severe rheumatoid arthritis affecting the hands, an occupational therapist can work with the client to develop strategies, adaptive equipment, and exercises to enhance hand function and promote independence in activities of daily living.
Correct Answer is C
Explanation
A. "You shouldn't worry about the future so you can concentrate on getting well.":
This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.
B. "If you work hard on your physical therapy, you won't need to worry.":
While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.
C. "You're concerned about what will happen when you leave the hospital?":
This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.
D. "Why are you concerned even though everyone is here to help you?":
This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.
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