A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?
Insert the needle at a 15-degree angle.
Aspirate for blood return before administration.
Administer the medication into the abdomen.
Massage the site after the injection.
The Correct Answer is C
Choice A rationale
Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.
Choice B rationale
Aspirating for blood return before administration is not necessary when administering heparin.
Choice C rationale
Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.
Choice D rationale
Massaging the site after the injection is not recommended as it can cause bruising.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.
Choice B rationale
Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.
Choice C rationale
Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.
Choice D rationale
Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.
Choice B rationale
The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.
Choice C rationale
The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.
Choice D rationale
Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.
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