A nurse is reinforcing teaching with a client who is to start subcutaneous heparin.
Which of the following information should the nurse include in the teaching?
Use a soft-bristled toothbrush.
Inject the medication deep into the thigh muscle.
Expect stools to become black and tarry.
Easy bruising indicates the medication is effective.
The Correct Answer is A
The nurse should include in the teaching that the client should use a soft-bristled toothbrush.
Heparin is an anticoagulant that decreases the clotting ability of the blood 1.
Using a soft-bristled toothbrush can help prevent bleeding of the gums while brushing teeth.
Choice B is incorrect because heparin should not be injected deep into the thigh muscle.
Instead, it should be given subcutaneously (under the skin) 2.
Choice C is incorrect because black and tarry stools are not an expected side effect of heparin.
Choice D is incorrect because easy bruising does not indicate that the medication is effective.
Instead, easy bruising may be a side effect of heparin and should be reported to the healthcare provider 1.
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Related Questions
Correct Answer is C
Explanation
The nurse should set the flow rate to deliver 40 gtts/min.
This can be calculated by multiplying the infusion rate (120 mL/hr) by the drop factor (60 gtt/mL) and then dividing by the number of minutes in an hour (60 min/hr): (120 mL/hr) * (60 gtt/mL) / (60 min/hr) = 120 gtt/min
Choice A is not the best answer because setting the flow rate to deliver 20 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice B is not the best answer because setting the flow rate to deliver 30 gtts/min would not provide the desired infusion rate of 120 mL/hr.
Choice D is not the best answer because setting the flow rate to deliver 50 gtts/min would provide a higher infusion rate than desired.
Correct Answer is ["A","C"]
Explanation
A client who has an understanding of the manifestations of hyperglycemia would know that their breath may have a fruity odor.
This is due to the presence of ketones, which are produced when the body breaks down fat for energy instead of using glucose.
Choice A is also correct.
Blurry vision can be a symptom of hyperglycemia.
High blood sugar levels can cause the lens of the eye to swell, leading to changes in vision.
Choice B is incorrect because hyperglycemia can cause an increase in appetite, not a decrease.
Choice D is incorrect because hyperglycemia can cause an increase in thirst, not a decrease.
This is due to the body’s attempt to flush out excess glucose through increased urination, which can lead to dehydration and increased thirst.
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