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 D
Explanation
D. Muscle weakness is a hallmark sign of hypokalemia. Potassium is crucial for proper muscle contraction, and low levels can impair muscle function. This weakness can affect skeletal muscles (resulting in fatigue, cramps, or generalized weakness) as well as smooth muscles (contributing to constipation or other gastrointestinal symptoms).
A. Hypokalemia is not typically associated with hyperactive bowel sounds.
B. Cerebral edema is not typically associated with hypokalemia. Instead, cerebral edema can occur with conditions such as hyponatremia (low sodium levels) or other metabolic disturbances.
C. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension. Low potassium levels can affect vascular smooth muscle tone, potentially leading to vasodilation and hypotension.
Correct Answer is C
Explanation
A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.
B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.
C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.
D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.
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