The nurse is teaching a client how to self-administer subcutaneous heparin injections.
Which instruction should the nurse include?

Inject in abdominal area at least 2 inches from the umbilicus.

Rotate injections between the abdomen and gluteal areas.

Massage the injection site to increase absorption.

Expel the air in the prefilled syringe prior to injection.

Answer and Explanation

The Correct Answer is A

Inject in abdominal area at least 2 inches from the umbilicus.

When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh.

Your tummy is usually best as the injection site and it is important that you change the site each time 1.

The heparin needs to go into the fat layer under the skin 2.

Choice B is incorrect because injections should not be rotated between the abdomen and gluteal areas.

Choice C is incorrect because massaging the injection site is not recommended.

Choice D is incorrect because air bubbles in a pre-filled syringe should not be expelled prior to injection 2.

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Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

A. Reinsert the peripheral IV catheter. B. Verify that the restraints can be quickly released. C. Assess capillary refill distal to the restraints. D. Replace the nasogastric tube.

Correct Answer is C

Explanation

When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.

This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.

Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.

Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.

Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.

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The nurse is teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

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Naxlex Comprehensive Predictor Exams

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The nurse is teaching a client how to self-administer subcutaneous heparin injections.
Which instruction should the nurse include?