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.

Massage the site after administering the medication.

Use a 21-gauge needle for the injection.

Aspirate before injecting the medication.

Answer and Explanation

The Correct Answer is A

This is because the umbilicus is a potential site of infection and should be avoided when administering subcutaneous heparin.

Choice B is wrong because massaging the site after administering the medication can cause bruising and hematoma formation.

Choice C is wrong because a 21-gauge needle is too large for subcutaneous injection and can cause tissue trauma and bleeding.

A smaller needle, such as 25- or 27-gauge, should be used.

Choice D is wrong because aspirating before injecting the medication can increase the risk of hematoma formation and is not recommended for subcutaneous heparin.

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Correct Answer is A

Explanation

The correct answer is choice A. Increased pulse rate.

An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.

Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.

Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.

Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.

A. Inject air into the NPH vial. B. Withdraw the NPH insulin from the vial. C. Withdraw the regular insulin from the vial. D. Inject air into the regular insulin vial.

Correct Answer is A

Explanation

The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:

Inject air into the NPH (intermediate-acting) insulin vial: Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.This also helps to equalize the pressure and makes it easier to withdraw the insulin.
Withdraw the regular insulin from the vial: The nurse should withdraw the regular insulin first because it is clear and not contaminated. This prevents any NPH insulin from mixing into the regular insulin vial.
Withdraw the regular insulin from the vial: Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin.

This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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