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

Answer and Explanation

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.

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Correct Answer is B, D, C, A

Explanation

A. Inject air into the NPH insulin vial: Start by injecting air into the NPH insulin vial. This step prevents creating a vacuum in the vial, making it easier to withdraw the correct dose of insulin.

B. Inject air into the regular insulin vial: After injecting air into the NPH insulin vial, inject air into the regular insulin vial. This step equalizes the pressure within the vial and makes it easier to withdraw the insulin.

C. Withdraw the regular insulin from the vial: Once the air has been injected into the regular insulin vial, withdraw the required dose of regular insulin from the vial.

D. Withdraw the NPH insulin from the vial: After withdrawing the regular insulin, withdraw the required dose of NPH insulin from its vial.

A. Urine specific gravity 1.020 B. BUN 28 mg/dl C. Serum hematocrit 55% D. Serum osmolarity 310 mOsm

Correct Answer is D

Explanation

A. Urine specific gravity 1.020: While this value indicates concentrated urine and can be useful in assessing dehydration, it doesn’t specifically confirm effective treatment. High urine specific gravity suggests dehydration because the kidneys are conserving water, but it doesn’t directly confirm the effectiveness of treatment.
B. BUN 28 mg/dl (Blood Urea Nitrogen): Elevated BUN levels can be seen in dehydration, but it's not a direct marker of effective treatment. It indicates dehydration due to increased urea concentration in the blood but doesn’t confirm if the treatment has been effective or not.
C. Serum hematocrit 55%: In dehydration, the blood becomes more concentrated due to water loss, causing an increase in hematocrit levels. However, while this value might indicate dehydration initially, it may not specifically confirm the effectiveness of treatment once initiated.
D. Serum osmolarity 310 mOsm: Serum osmolarity measures the concentration of particles in the blood. In dehydration, the blood becomes more concentrated, leading to increased serum osmolarity. When treatment is effective, rehydration occurs, diluting the blood and bringing serum osmolarity back toward normal levels. Therefore, a decrease in serum osmolarity towards the normal range (280-300 mOsm) would indicate effective treatment of dehydration

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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