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.

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Correct Answer is A

Explanation

A. Insert the needle at a 45° or 90° angle. Enoxaparin is administered subcutaneously, and subcutaneous injections should be given at either a 45° or 90° angle, depending on the client’s body size and the amount of subcutaneous tissue available. A 90° angle is typically used for clients with more subcutaneous tissue, while a 45° angle is appropriate for those with less.

B. Hold the skin taut during administration. When giving subcutaneous injections, the skin should be gently pinched rather than held taut. Pinching helps ensure the medication is delivered into the fatty tissue rather than the muscle, reducing the risk of intramuscular injection, which can increase bleeding risk with anticoagulants like enoxaparin.

C. Massage the injection site after administering the enoxaparin. Massaging the injection site is contraindicated because it can cause tissue irritation, bruising, and increased risk of bleeding. Instead, gentle pressure may be applied with a gauze pad if necessary to minimize bleeding.

D. Use a 4 cm (1.6 in) needle. A needle length of 4 cm (1.6 inches) is too long for a subcutaneous injection and increases the risk of intramuscular administration, which could lead to increased bleeding and bruising. The recommended needle length for subcutaneous injections is typically ½ inch (1.25 cm) to ⅝ inch (1.6 cm) to ensure proper medication delivery.

A. Jaundice B. Urticaria C. Bradycardia D. Hypertension

Correct Answer is B

Explanation

A. Jaundice. Jaundice, or yellowing of the skin and eyes, is a sign of liver dysfunction and may indicate hepatotoxicity rather than an allergic reaction. Some medications can cause drug-induced liver injury (DILI), but jaundice is not a typical symptom of an immediate hypersensitivity reaction.

B. Urticaria. Urticaria (hives) is a classic allergic reaction that appears as raised, red, itchy welts on the skin. It occurs due to the release of histamine in response to an allergen, which increases capillary permeability and leads to swelling and itching. Urticaria may be accompanied by angioedema, respiratory distress, or anaphylaxis, requiring immediate intervention if severe.

C. Bradycardia. Bradycardia (slow heart rate) is not a typical manifestation of an allergic reaction. While anaphylaxis can cause hypotension and tachycardia due to systemic vasodilation, bradycardia is more commonly associated with beta-blockers, heart block, or vagal stimulation rather than an allergic response.

D. Hypertension. Allergic reactions, especially severe ones like anaphylaxis, typically cause vasodilation and hypotension, not hypertension. While stress or anxiety related to an allergic episode may lead to a temporary rise in blood pressure, persistent hypertension is not a direct sign of an allergic reaction.

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

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