A nu’se is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take to minimize bleeding following the injection?
Grasp skin between thumb and forefinger throughout the injection.
Aspirate the syringe prior to injecting the heparin.
Use the Z-track method to administer the medication.
Gently massage the site following the injection.
The Correct Answer is A
A) Grasp skin between thumb and forefinger throughout the injection: This is the correct answer. Grasping the skin between the thumb and forefinger creates tension, which helps to stabilize the tissue during the injection. This technique reduces the risk of tissue damage and minimizes bleeding following the injection of heparin subcutaneously.
B) Aspirate the syringe prior to injecting the heparin: Aspiration is not necessary for subcutaneous injections, as the risk of intravascular injection is minimal. Aspirating the syringe can increase discomfort for the client and is not recommended for subcutaneous injections.
C) Use the Z-track method to administer the medication: The Z-track method is used for intramuscular injections to minimize medication leakage into the subcutaneous tissue. However, heparin is typically administered subcutaneously, and the Z-track method is not appropriate for this route of administration.
D) Gently massage the site following the injection: Massaging the site following a subcutaneous injection of heparin can increase the risk of bleeding and hematoma formation. Therefore, this action should be avoided to minimize bleeding at the injection site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Hematuria: Hematuria, or blood in the urine, is not typically associated with an allergic reaction to cefaclor. Allergic reactions usually manifest with symptoms such as rash, itching, swelling, or difficulty breathing. Hematuria is more likely indicative of a urinary tract infection, kidney stones, or another non-allergic issue.
B) Pruritus: Pruritus, or itching, is a common symptom of an allergic reaction to medications like cefaclor. Itching can occur on the skin or mucous membranes and may be accompanied by other allergic symptoms such as rash, hives, or swelling. Therefore, the presence of pruritus should raise suspicion for a potential allergic reaction to cefaclor.
C) Slurred speech: Slurred speech is not a typical manifestation of an allergic reaction to cefaclor. It is more commonly associated with neurological conditions, intoxication, stroke, or side effects of certain medications, rather than an allergic response to antibiotics.
D) Tremor: Tremor, or involuntary shaking, is not a characteristic sign of an allergic reaction to cefaclor. Tremors can have various causes, including neurological disorders, medication side effects, or metabolic abnormalities. While tremors can occur in severe allergic reactions (anaphylaxis), they are not among the primary symptoms.
Correct Answer is C
Explanation
A) Pain level: Assessing the client's pain level may be important for administering analgesic medications, but it is not directly related to the administration of propranolol. Propranolol is a beta-blocker primarily used to treat conditions such as hypertension, angina, and certain cardiac arrhythmias, so assessing pain level is not the priority.
B) Respiratory rate: While monitoring respiratory rate is important in various clinical situations, propranolol administration does not typically have a direct effect on respiratory function. Therefore, assessing the respiratory rate specifically before administering propranolol may not be as relevant as other vital signs.
C) Heart rate: Propranolol is a beta-blocker that primarily works by slowing the heart rate and reducing the workload on the heart. Therefore, it is crucial for the nurse to assess the client's heart rate prior to administering propranolol to ensure it is within the appropriate range. Administering propranolol to a client with bradycardia or a significantly low heart rate could exacerbate this condition and lead to adverse effects.
D) Temperature: While monitoring temperature is important for assessing for signs of infection or other systemic issues, it is not directly relevant to the administration of propranolol. Propranolol primarily affects cardiovascular function, so assessing temperature is not typically a priority before administering this medication.
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