A nurse is preparing to administer heparin subcutaneously to a client.
Which of the following is an appropriate action by the nurse?
Use a 1-inch needle to inject the medication.
Use a 22-gauge needle to inject the medication.
Massage the injection site after administration of the medication.
Inject the medication into the abdomen above the level of the iliac crest.
The Correct Answer is D
“Inject the medication into the abdomen above the level of the iliac crest.” When administering heparin subcutaneously, it is appropriate to inject the medication into the abdomen above the level of the iliac crest 1.
Choice A is not correct because a 1-inch needle may be too long for subcutaneous injection.
A shorter needle, such as a 3/8 to 5/8 inch needle, is typically used for subcutaneous injections.
Choice B is not correct because a 22-gauge needle may be too large for subcutaneous injection.
A smaller gauge needle, such as a 25- or 27-gauge needle, is typically used for subcutaneous injections.
Choice C is not correct because massaging the injection site after administering heparin can increase the risk of bruising and should be avoided.
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Correct Answer is D
Explanation
“Inject the medication into the abdomen above the level of the iliac crest.” When administering heparin subcutaneously, it is appropriate to inject the medication into the abdomen above the level of the iliac crest 1.
Choice A is not correct because a 1-inch needle may be too long for subcutaneous injection.
A shorter needle, such as a 3/8 to 5/8 inch needle, is typically used for subcutaneous injections.
Choice B is not correct because a 22-gauge needle may be too large for subcutaneous injection.
A smaller gauge needle, such as a 25- or 27-gauge needle, is typically used for subcutaneous injections.
Choice C is not correct because massaging the injection site after administering heparin can increase the risk of bruising and should be avoided.
Correct Answer is A
Explanation
The nurse should inform the charge nurse about her suspicion.
The charge nurse is responsible for managing the unit and can take appropriate action to investigate the matter and ensure that proper procedures are followed.
Choice B is incorrect because reporting the incident to the hospital security department is not the first step that should be taken.
The charge nurse should be informed first and can then decide if further action, such as involving the security department, is necessary.
Choice C is incorrect because it is not appropriate for the nurse to ask assistant personnel (AP) to observe the other nurse’s actions.
This could create a hostile work environment and may not be an effective way to address the issue.
Choice D is incorrect because approaching the other nurse directly to discuss the suspicion may not be the best course of action.
It could create tension and conflict between the two nurses and may not lead to a resolution of the issue.
Instead, informing the charge nurse allows for proper procedures to be followed in addressing the matter.
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