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 B
Explanation
A. Loosen the client's clothing:
While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.
B. Help the client lie on the floor:
This is the correct answer. When a client is having a seizure, the priority is to ensure their safety. Lying the client on the floor helps prevent injury during the seizure, reducing the risk of falling from a chair or bed. Placing the client in a lateral (side) position can also help maintain an open airway.
C. Turn the client onto their side:
This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.
D. Move items in the room away from the client:
While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.
Correct Answer is A
Explanation
A. "It's nice having other people cook for me.":
This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.
B. "I've never been the kind of person to ask others for help.":
This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.
C. "I'm looking forward to being able to be independent again.":
This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.
D. "I really don't know what I'm supposed to do all day.":
This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.
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