A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?
Insert the needle at least 5 cm (2 in) from the umbilicus.
Aspirate before injecting the medication.
Massage the site after administering the medication.
Use a 21-gauge needle for the injection.
The Correct Answer is A
A. Insert the needle at least 5 cm (2 in) from the umbilicus: Correct. Subcutaneous injections, including heparin, should be given in fatty tissue away from major blood vessels and bony prominences. The recommended sites are usually the abdomen, thighs, or upper arms.
B. Aspirate before injecting the medication: Incorrect. Aspiration is not required for subcutaneous injections because they are administered into the subcutaneous fat layer, not a blood vessel. Aspiration could cause trauma and discomfort to the client.
C. Massage the site after administering the medication: Incorrect. Massaging the site after administering heparin can cause bruising or discomfort. Instead, it's recommended to apply gentle pressure with a sterile gauze pad for a few seconds.
D. Use a 21-gauge needle for the injection: Incorrect. Subcutaneous injections are typically administered with smaller gauge needles, such as 25-30 gauge, to minimize pain and tissue damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer the medication into the client's muscles.
Explanation: This is incorrect because enoxaparin is usually administered subcutaneously, not into the muscle.
B. Apply firm pressure to the injection site following administration.
Explanation: This is incorrect because while applying gentle pressure after a subcutaneous injection is common practice, it is not specific to enoxaparin.
C. Insert the syringe needle halfway into the client's skin.
Explanation: This is incorrect because the needle should be inserted fully into the subcutaneous tissue, not just halfway, for proper administration of enoxaparin.
D. Expel the air bubble from the syringe prior to injection.
Explanation: This is the correct action. Expelling air bubbles from the syringe prior to injection helps ensure accurate dosing and prevents air from being injected into the subcutaneous tissue.
When administering enoxaparin (low molecular weight heparin) subcutaneously, it's important to expel any air bubbles from the syringe before injection. Air bubbles can cause discomfort and inaccuracies in dosage. The nurse should gently tap the syringe to move air bubbles to the top and then push the plunger slightly to expel the air. The other options are not correct procedures for administering enoxaparin. It is typically injected into the subcutaneous tissue, not a muscle, and firm pressure is not typically applied after administration. The needle is fully inserted into the skin, not halfway.
Correct Answer is D
Explanation
A. Decrease in protein:
This choice is incorrect. Albumin is a protein found in the blood, and when a client is receiving an infusion of albumin, it is likely to increase, not decrease, the overall protein level in the bloodstream. Albumin infusions are often given to help increase plasma oncotic pressure and improve fluid retention in conditions like shock.
B. Oxygen saturation 96%:
This choice is incorrect. Oxygen saturation of 96% is within the normal range and reflects adequate oxygenation. It doesn't directly relate to the administration of albumin in shock.
C. PaCO2 30 mm Hg:
This choice is incorrect. The partial pressure of carbon dioxide (PaCO2) of 30 mm Hg reflects a respiratory value and doesn't directly relate to the administration of albumin or the management of shock. It's important for assessing acid-base balance, but it's not a specific finding related to the albumin infusion.
D. Increase in BP:
This is the correct choice. Albumin is a colloid solution that helps increase the oncotic pressure within blood vessels, which can contribute to an increase in blood volume. When blood volume increases, it can lead to an increase in blood pressure, which is a desired effect in the management of shock. Increasing blood pressure helps improve perfusion to vital organs and tissues, which is essential in shock situations.
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