A nurse is preparing to administer heparin subcutaneously to an obese client who has a deep vein thrombosis. Which of the following actions should the nurse take?
Select a 22-gauge needle for heparin administration.
Insert the needle at a 90° angle.
Massage the injection site after administering the heparin.
Aspirate for a blood return prior to injecting the heparin.
The Correct Answer is B
B. Subcutaneous injections are generally administered at a 45° or 90° angle, depending on the amount of subcutaneous tissue present. In obese clients, there is typically more subcutaneous tissue, so inserting the needle at a 90° angle may be necessary to ensure proper medication absorption.
A. A smaller gauge needle (such as 25 or 26 gauge) is usually more appropriate for subcutaneous injections to minimize discomfort and tissue trauma, especially in obese clients where there is more subcutaneous tissue.
C. Massaging the injection site after administering heparin is not recommended. It can cause discomfort, bruising, and potentially alter the absorption rate of the medication. The injection site should be gently
pressed with a dry gauze pad after withdrawal of the needle to help disperse the medication and prevent leakage, but massaging should be avoided.
D. Aspiration is not necessary for subcutaneous injections. It is generally used for intramuscular injections to ensure the needle is not in a blood vessel, which is less of a concern for subcutaneous injections. The injection technique involves pinching the skin and injecting the medication into the subcutaneous tissue without aspirating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pantoprazole belongs to a class of medications called proton pump inhibitors (PPIs), which work by reducing the production of gastric acid in the stomach. This helps in treating conditions such as gastroesophageal reflux disease (GERD) and heartburn effectively.
B. Pantoprazole is not known to cause hyperkalemia. Hyperkalemia is a condition characterized by high levels of potassium in the blood, and it is typically associated with certain medications (e.g., potassium- sparing diuretics) or medical conditions affecting kidney function. Pantoprazole's primary side effects relate to its effects on gastric acid production and absorption of certain nutrients.
C. While pantoprazole is usually taken once daily, the timing of administration is typically in the morning, before a meal. This helps to maximize its effectiveness in reducing gastric acid secretion when the stomach acid production is at its highest.
D. Pantoprazole should be taken on an empty stomach, at least 30 minutes before a meal. This timing allows the medication to be absorbed properly and work effectively to reduce gastric acid production.
Correct Answer is B
Explanation
B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.
A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.
C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.
D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.
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