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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pruritus, which is itching, is a common adverse effect associated with the use of opioids, including morphine. Itching can occur when opioids are administered through various routes, including epidural infusion. The exact mechanism for opioid-induced itching is not fully understood, but it is thought to be related to the release of histamines or other chemical mediators.
B. Gastric bleeding is not a common adverse effect of epidurally administered opioids like morphine. Gastric bleeding is more associated with non-steroidal anti-inflammatory drugs (NSAIDs) and certain other medications.
C & D. Tachypnea (rapid breathing) and cough are not typical adverse effects of epidurally administered opioids. However, opioids can cause respiratory depression (slow and shallow breathing), so monitoring respiratory status is important when using these medications.
Correct Answer is D
Explanation
A. Bradycardia:
Incorrect Explanation: Bradycardia (slow heart rate) is not a common adverse effect of phenytoin.
Explanation: Phenytoin primarily affects the central nervous system and is not known to cause significant cardiovascular effects like bradycardia.
B. Red man syndrome:
Incorrect Explanation: Red man syndrome is associated with some antibiotics, not phenytoin.
Explanation: Red man syndrome, characterized by redness and flushing of the skin, is primarily associated with certain antibiotics like vancomycin and is not a recognized adverse effect of phenytoin.
C. Hypoglycemia:
Incorrect Explanation: Hypoglycemia is not a common adverse effect of phenytoin.
Explanation: Phenytoin does not have a direct impact on blood glucose levels, so hypoglycemia is not a typical adverse effect.
D. Hypotension:
Correct Answer: Hypotension (low blood pressure) is an adverse effect that the nurse should identify as a potential concern with phenytoin administration.
Explanation: Phenytoin, especially when administered rapidly as an IV bolus, can lead to hypotension as one of its adverse effects. Monitoring blood pressure during and after administration is important.
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