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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "This is an expected adverse effect of the medication." Rifampin commonly causes red-orange discoloration of bodily fluids, including saliva, tears, urine, and sweat. This occurs due to the drug's excretion and is harmless. It does not indicate internal bleeding or organ dysfunction. Clients should be educated about this side effect in advance to prevent alarm and unnecessary discontinuation of the medication, as adherence to tuberculosis treatment is crucial.

B. "Stop taking the medication. You are having an allergic reaction." The red discoloration caused by rifampin is a known side effect, not an allergic reaction. A true allergic response would include symptoms such as rash, itching, swelling, or difficulty breathing. Stopping rifampin without medical advice could disrupt tuberculosis treatment, leading to drug resistance or treatment failure, making this an inappropriate recommendation.

C. "This condition will only last a couple of days." The discoloration of bodily fluids persists throughout the duration of rifampin therapy. Tuberculosis treatment can last several months, so the client should expect this effect to continue as long as they are taking the medication. Providing incorrect information may cause the client to worry unnecessarily when the discoloration does not resolve quickly.

D. "Taking the medication with red meat will cause this adverse effect." The discoloration is due to rifampin’s chemical properties and metabolism, not dietary intake. Red-colored foods, such as red meat or berries, do not influence this effect. Providing inaccurate dietary information may lead to unnecessary dietary restrictions, which are not needed for managing this side effect.

A. A pregnant parent B. Receiving treatment for leukemia C. Taking acetaminophen for mild discomfort D. An allergy to eggs

Correct Answer is B

Explanation

A. A pregnant parent. A child can receive the varicella vaccine even if the parent is pregnant. While the varicella vaccine is a live attenuated vaccine, the vaccinated child does not pose a significant risk of transmission to others. The parent should avoid direct contact with the vaccinee's rash if one develops, but this is not a contraindication to immunization.

B. Receiving treatment for leukemia. Children undergoing treatment for leukemia often have weakened immune systems due to chemotherapy or radiation. The varicella vaccine is a live attenuated vaccine, meaning it contains a weakened form of the virus that could cause severe illness in immunocompromised individuals. These children should not receive live vaccines until their immune function improves and their healthcare provider approves vaccination.

C. Taking acetaminophen for mild discomfort. Acetaminophen is an over-the-counter pain reliever and fever reducer that does not interfere with the efficacy or safety of the varicella vaccine. There is no evidence that mild analgesic use before or after vaccination affects immune response, so it is not a reason to withhold the immunization.

D. An allergy to eggs. Unlike some influenza and yellow fever vaccines, the varicella vaccine is not produced using egg-based components. An egg allergy is not a contraindication to receiving the varicella vaccine, as it does not contain egg proteins.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is administering heparin subcutaneously to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic receives a telephone call from a client who has tuberculosis and was prescribed rifampin 3 days ago. The client reports, "My saliva and tears are red. What should I do?" Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?

Correct Answer is B

Explanation

A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?

A nurse is preparing to administer morphine 0.1 mg/kg IM to a school-age child who weighs 66 lb. What is the dose that the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for haloperidol. The nurse should instruct the client to avoid taking which of the following medications?

A nurse is caring for a client who has chronic liver disease. Which of the following medications should the nurse recognize as appropriate for this client?

A nurse is reinforcing teaching with a client who is to start therapy with furosemide. The nurse determines that the teaching is effective when the client states he will increase intake of which of the following foods?

A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?

A nurse is caring for a client who has chronic renal failure and is receiving epoetin alfa. To check for therapeutic effects, the nurse should monitor which of the following client laboratory tests?