A charge nurse is teaching a newly licensed nurse about administering heparin to a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
I will check the client's INR before administering the heparin
"I will apply pressure for 1 minute after the Injection
I will massage the site after the injecting the heparin
I will aspirate before administering the heparin
None
None
The Correct Answer is B
A. I will check the client's INR before administering the heparin:
Checking the International Normalized Ratio (INR) is more relevant for monitoring the effects of warfarin, not heparin. Heparin is typically monitored by activated partial thromboplastin time (aPTT) or anti-Xa levels.
B. "I will apply pressure for 1 minute after the injection:"
Applying gentle pressure to the injection site for about 1 minute after administering heparin is appropriate to prevent bleeding or bruising. Since heparin is an anticoagulant, there's an increased risk of bleeding at the injection site.
C. I will massage the site after injecting the heparin:
Massaging the site after injecting heparin is not recommended. It can increase the risk of hematoma formation. After subcutaneous injection, it is generally advised to avoid massaging the site.
D. I will aspirate before administering the heparin:
Aspiration is not recommended when administering heparin subcutaneously, as it can increase the risk of tissue damage and bruising. The nurse should inject the heparin without aspirating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. "Take the medication with an antacid if it upsets your stomach."
Explanation: Antacids may interfere with the absorption of iron. It is generally recommended to take iron supplements on an empty stomach or with vitamin C-containing foods to enhance absorption.
B. "Stop taking the medication if your stools become green or black."
Explanation: Ferrous sulfate can cause stools to become dark green or black, which is a normal and expected side effect. However, excessive black, tarry stools may indicate gastrointestinal bleeding and should be reported to the healthcare provider.
C. "Drink the elixir using a straw to prevent staining your teeth."
Explanation: Ferrous sulfate elixir can stain the teeth. Using a straw helps bypass direct contact with the teeth, reducing the risk of staining.
D. "Increase your fiber intake to prevent constipation."
Explanation: Iron supplements, including ferrous sulfate, can cause constipation. Increasing fiber intake can help alleviate constipation.
E. "Increase your intake of dairy products to increase the absorption of this medication."
Explanation: Calcium-containing foods, such as dairy products, can inhibit the absorption of iron. It is advisable to take iron supplements separately from calcium-containing foods.
Correct Answer is B
Explanation
A. "Lie down for 1 hour after administering the medication.": This statement is not necessary for nasal cyanocobalamin administration. There is no need for the client to lie down for an extended period after administering the medication.
B. "Administer the medication into one nostril once per week.": This is the correct information. Nasal cyanocobalamin is typically administered once a week for the treatment of pernicious anemia. It's important for the nurse to emphasize the correct frequency and route of administration to ensure the effectiveness of the treatment.
C. "Plan to self-administer this medication for the next 6 months.": The duration of treatment may vary based on the healthcare provider's prescription. The nurse should instruct the client based on the specific instructions provided by the healthcare provider rather than a predetermined time frame.
D. "Use a nasal decongestant 15 minutes before the medication if you have a stuffy nose.": This statement is not a standard recommendation for nasal cyanocobalamin administration. If the client has concerns about a stuffy nose, they should consult with their healthcare provider rather than using a nasal decongestant without guidance.
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