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 C
Explanation
A. Acetaminophen: Acetaminophen is not an antihistamine and does not typically interfere with allergy testing. It can be safely continued before the procedure.
B. Pseudoephedrine hydrochloride: Pseudoephedrine is a decongestant and does not directly interfere with the results of allergy testing. It is not necessary to avoid pseudoephedrine for this purpose.
C. Diphenhydramine: Diphenhydramine is an antihistamine and should be avoided for up to 4 weeks before allergy testing to ensure accurate results. Other antihistamines should also be discontinued for the same duration.
D. Albuterol: Albuterol is a bronchodilator and does not interfere with the results of allergy testing. It can be continued before the procedure.
Correct Answer is A
Explanation
A. Visual disturbances:
Visual disturbances, such as blurred or yellow-tinted vision, are common signs of digoxin toxicity. Clients should report any changes in vision promptly.
B. Potassium 4.4 mEq/L:
While electrolyte imbalances, particularly low potassium levels, can increase the risk of digoxin toxicity, a potassium level of 4.4 mEq/L is within the normal range and, by itself, does not indicate digoxin toxicity.
C. Insomnia:
Insomnia is not a typical sign of digoxin toxicity. Symptoms of toxicity are more likely to involve the gastrointestinal and visual systems.
D. Sudden weight gain:
Sudden weight gain can be a symptom of heart failure exacerbation but is not a direct indication of digoxin toxicity. Other signs, such as visual disturbances, are more specific to digoxin toxicity.
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