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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.

A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.

B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.

D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.

A. Stop taking this medication if you develop constipation. B. Take the medication on an empty stomach. C. Take an antacid at the same time you take this medication. D. Remain upright for 30 min after taking this medication.

Correct Answer is B

Explanation

B. Sucralfate should be taken on an empty stomach, at least 1 hour before meals or 2 hours after meals, to maximize its effectiveness. Food can interfere with its ability to coat the stomach lining.

A. Constipation is a common side effect of sucralfate, but it does not typically require discontinuation of the medication. Instead, clients are often advised to manage constipation with dietary fiber, fluids, and sometimes mild laxatives if necessary.

C. Antacids can interfere with sucralfate by altering its pH-dependent activation and should not be taken simultaneously. If antacids are necessary for symptom relief, they should be taken at least 30 minutes before or after sucralfate.

D. There is no specific instruction to remain upright after taking sucralfate

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a duodenal ulcer and has a new prescription for sucralfate. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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