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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale

A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.

Choice B rationale

The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.

Choice C rationale

The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.

Choice D rationale

The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.

A. Admitting diagnosis B. Breath sounds C. Body temperature D. Diagnostic test results

Correct Answer is B

Explanation

When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.

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A nurse is instructing a patient on how to self-administer heparin. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present. Which observation should the nurse identify as a potential sign of elder abuse?

Correct Answer is C

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A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

Correct Answer is B

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