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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Migraines are not a contraindication for propranolol. In fact, propranolol is used as a prophylactic treatment for migraines, as it reduces the frequency and severity of migraine attacks.
Choice B reason: Glaucoma is not a contraindication for propranolol. Propranolol does not affect the intraocular pressure or the drainage of aqueous humor in the eye.
Choice C reason: Asthma is a contraindication for propranolol. Propranolol is a nonselective beta-blocker, which means it blocks both beta-1 and beta-2 receptors in the body. Beta-2 receptors are found in the bronchial smooth muscle, and when they are blocked, they cause bronchoconstriction and increased airway resistance. This can worsen the symptoms of asthma and cause a life-threatening asthma attack.
Choice D reason: Depression is not a contraindication for propranolol. Propranolol does not cause depression, although it may cause some side effects such as fatigue, insomnia, and sexual dysfunction. However, these side effects are usually mild and reversible.
Correct Answer is D
Explanation
Choice A reason: Taking only one dose of nitroglycerin is not a good advice, as it may not be enough to relieve the angina pain and prevent a myocardial infarction. Nitroglycerin is a vasodilator that relaxes the blood vessels and improves the blood flow to the heart. The recommended dose is one tablet or spray under the tongue every 5 minutes for up to three doses, or until the pain is relieved. Taking only one dose may compromise the effectiveness of the medication and the safety of the client.
Choice B reason: Asking the provider to prescribe a different medication is not a necessary action, as nitroglycerin is a first-line treatment for stable angina and has proven benefits for reducing mortality and morbidity. Changing the medication may not be appropriate or feasible, as there may not be a suitable alternative that has the same efficacy and safety profile. The client should continue taking nitroglycerin as prescribed, unless the provider decides otherwise.
Choice C reason: Saying that there's nothing that can be done to relieve the headaches is not a true or helpful statement, as there are some measures that can help reduce or prevent the headaches. Headaches are a common and expected side effect of nitroglycerin, as it dilates the blood vessels in the brain and causes increased intracranial pressure. However, the headaches usually subside over time as the body adapts to the medication. The client can also take a mild analgesic, such as acetaminophen or ibuprofen, to relieve the headache, as long as it does not interact with the nitroglycerin or other medications.
Choice D reason: Trying to take a mild analgesic to relieve the headache is a reasonable and appropriate suggestion, as it can help alleviate the discomfort and improve the quality of life of the client. The client should choose an analgesic that is safe and effective, such as acetaminophen or ibuprofen, and follow the directions on the label. The client should also consult the provider or the pharmacist before taking any over-the-counter medications, as some of them may interact with nitroglycerin or other medications. The client should also avoid aspirin, as it may increase the risk of bleeding.
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