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 B

Explanation

B. Dextrose 10% in water is a solution that contains a high concentration of glucose (dextrose). Infusing D10W can lead to an increase in blood glucose levels, especially if the client's body cannot metabolize the glucose effectively (e.g., in diabetic patients or those with impaired glucose tolerance).

A. Dextrose 10% in water does not contain calcium. Hypercalcemia refers to elevated calcium levels in the blood, which can occur due to various causes such as hyperparathyroidism or excessive vitamin D intake, but not from D10W infusion.

C. Dextrose 10% in water is not used to treat hypovolemia (low blood volume). It is a solution primarily used to provide calories and prevent ketosis rather than to expand circulating blood volume.

D. Dextrose 10% in water does not contain potassium. Hypokalemia (low potassium levels) can occur due to various reasons such as diuretic use, gastrointestinal losses, or inadequate intake, but it is not directly related to D10W infusion.

A. Intake 2,400 mL, output 2.500 mL B. Intake 1,200 mL, output 700 mL C. Intake 800 mL output 2,100 mL D. Intake 2.500 mL output 500 mL

Correct Answer is A

Explanation

A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.

B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.

C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.

D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.

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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

A nurse is assisting with the care of a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

Correct Answer is A

Explanation

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

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