A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?

Inject the medication into the abdomen above the level of the iliac crest.

Massage the injection site after administration of the medication.

Use a 1-inch needle to inject the medication.

Use a 22-gauge needle to inject the medication.

Answer and Explanation

The Correct Answer is A

Choice A reason: Injecting the medication into the abdomen above the level of the iliac crest is the correct action. This is the preferred site for heparin administration, as it has fewer blood vessels and nerves, and allows for better absorption of the medication. The nurse should avoid the area around the umbilicus, as it may have increased bleeding and bruising.

Choice B reason: Massaging the injection site after administration of the medication is not the correct action. This may cause hematoma formation, tissue irritation, and reduced effectiveness of the medication. The nurse should apply gentle pressure to the injection site for 1 to 2 minutes after administration.

Choice C reason: Using a 1-inch needle to inject the medication is not the correct action. This may cause pain, tissue damage, and bleeding. The nurse should use a 25- to 28-gauge needle that is 3/8 to 5/8 inch long to inject the medication.

Choice D reason: Using a 22-gauge needle to inject the medication is not the correct action. This may cause pain, tissue damage, and bleeding. The nurse should use a 25- to 28-gauge needle that is 3/8 to 5/8 inch long to inject the medication.

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Correct Answer is B

Explanation

Choice A reason: Blood pressure 160/94 mm Hg is not a reason to withhold atenolol, as it is a beta-blocker that lowers blood pressure and reduces the workload of the heart. Atenolol is indicated for hypertension, angina, and arrhythmias. The nurse should administer atenolol as prescribed, unless the blood pressure is too low (hypotension).

Choice B reason: Heart rate 46/min is a reason to withhold atenolol, as it is a sign of bradycardia (slow heart rate), which can be a side effect of atenolol. Atenolol can decrease the heart rate by blocking the beta-1 receptors in the heart. The nurse should withhold atenolol if the heart rate is below 60 beats per minute or above 100 beats per minute, and report the finding to the provider.

Choice C reason: Oxygen saturation 95% is not a reason to withhold atenolol, as it is a normal value that indicates adequate oxygenation of the blood. Atenolol does not affect the oxygen saturation or the respiratory function. The nurse should monitor the oxygen saturation regularly, and report any signs of hypoxia (low oxygen level).

Choice D reason: Respiratory rate 18/min is not a reason to withhold atenolol, as it is a normal value that indicates normal breathing. Atenolol does not affect the respiratory rate or the respiratory function. The nurse should monitor the respiratory rate regularly, and report any signs of dyspnea (difficulty breathing).

A. Reduce intake of potassium-rich foods. B. Avoid grapefruit juice. C. Take this medication before bedtime. D. Monitor for leg cramps.

Correct Answer is D

Explanation

Choice A reason: Reducing intake of potassium-rich foods is not necessary for clients taking hydrochlorothiazide, as this medication can cause hypokalemia (low potassium levels) due to increased potassium excretion in the urine. Clients may need to increase their intake of potassium-rich foods or take potassium supplements to prevent hypokalemia.

Choice B reason: Avoiding grapefruit juice is not necessary for clients taking hydrochlorothiazide, as this medication does not interact with grapefruit juice. Grapefruit juice can affect the metabolism of some other medications, such as statins, calcium channel blockers, and cyclosporine, by inhibiting the enzyme CYP3A4 in the liver.

Choice C reason: Taking this medication before bedtime is not advisable for clients taking hydrochlorothiazide, as this medication can cause increased urination and nocturia (nighttime urination). Clients should take this medication in the morning or at least 6 hours before bedtime to avoid disrupting their sleep.

Choice D reason: Monitoring for leg cramps is an important instruction for clients taking hydrochlorothiazide, as this medication can cause muscle cramps due to electrolyte imbalances, such as hypokalemia, hyponatremia (low sodium levels), or hypomagnesemia (low magnesium levels). Clients should report any signs of muscle cramps, weakness, or fatigue to their provider.

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A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client prior to administering atenolol. Which of the following findings should prompt the nurse to withhold the medication?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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