A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?
Aspirate before injecting the medication
Use a 25-gauge, 1/2-inch needle to administer the medication
Administer the medications within 2 cm (1 in) of the umbilicus
Massage the site after injecting the medication.
The Correct Answer is B
A. Aspirate before injecting the medication. Aspirating before injecting heparin is not recommended because it can cause tissue trauma and increase the risk of hematoma formation. Heparin is administered into the subcutaneous tissue, which has fewer blood vessels than intramuscular tissue, making aspiration unnecessary. Aspiration can also lead to bruising and discomfort, which should be minimized when administering anticoagulants.
B. Use a 25-gauge, 1/2-inch needle to administer the medication. Heparin should be administered using a small-gauge (25- to 27-gauge) needle with a length of 1/2 to 5/8 inch to reduce tissue trauma and minimize the risk of bleeding. The small needle size helps ensure that the medication is delivered into the subcutaneous tissue rather than deeper layers. Proper needle selection is important to prevent bruising and irritation, which are common concerns when administering anticoagulants.
C. Administer the medication within 2 cm (1 in) of the umbilicus. Heparin should not be injected near the umbilicus because this area has a higher density of blood vessels and an increased risk of bruising. The preferred injection sites are the abdomen (at least 5 cm or 2 inches away from the umbilicus), the upper outer thigh, or the outer upper arm. Injecting in these areas ensures proper absorption while minimizing complications such as hematoma formation.
D. Massage the site after injecting the medication. Massaging the injection site after administering heparin is contraindicated because it can lead to increased bruising, tissue irritation, and the potential for excessive bleeding. Instead of massaging, gentle pressure can be applied with a gauze pad if necessary to control minor bleeding. Clients should be advised to avoid rubbing or applying unnecessary pressure to the injection site to reduce the risk of local complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["6"]
Explanation
Calculate the total daily dose:
Total daily dose (mg) = Weight (kg) x Dosage (mg/kg/day)
=14.9 kg x 40 mg/kg/day
= 596 mg/day
Calculate the dose per administration (divided into two doses):
Dose per administration (mg) = Total daily dose (mg) / Number of doses
= 596 mg/day / 2 doses
= 298 mg/dose
Calculate the volume to administer per dose:
Volume (mL) = Desired dose (mg) / Available concentration (mg/mL)
Available concentration = 250 mg / 5 mL
= 50 mg/mL
Volume (mL) = 298 mg / 50 mg/mL
= 5.96 mL/dose
Round to the nearest whole number:
5.96 mL is 6 mL/dose
Correct Answer is D
Explanation
A. Atropine. Atropine is an anticholinergic medication used to treat bradycardia and reduce secretions before surgery. It has no effect on reversing anticoagulation caused by heparin and would not be an appropriate treatment for heparin overdose.
B. Vitamin K. Vitamin K is used as an antidote for warfarin toxicity, as it helps produce clotting factors that warfarin inhibits. However, it does not reverse the effects of heparin, which works by enhancing the activity of antithrombin to prevent clot formation.
C. Vitamin B12. Vitamin B12 is essential for red blood cell production and neurological function, primarily used to treat conditions like pernicious anemia. It does not have any role in reversing the anticoagulant effects of heparin and would not be beneficial in this situation.
D. Protamine. Protamine sulfate is the specific antidote for heparin overdose. It binds to heparin, neutralizing its anticoagulant effects and preventing excessive bleeding. Protamine is administered intravenously in cases of heparin toxicity or when urgent reversal is needed, such as before surgery or in cases of uncontrolled bleeding.
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