A nu’se is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take to minimize bleeding following the injection?

Grasp skin between thumb and forefinger throughout the injection.

Aspirate the syringe prior to injecting the heparin.

Use the Z-track method to administer the medication.

Gently massage the site following the injection.

Answer and Explanation

The Correct Answer is A

A) Grasp skin between thumb and forefinger throughout the injection: This is the correct answer. Grasping the skin between the thumb and forefinger creates tension, which helps to stabilize the tissue during the injection. This technique reduces the risk of tissue damage and minimizes bleeding following the injection of heparin subcutaneously.

B) Aspirate the syringe prior to injecting the heparin: Aspiration is not necessary for subcutaneous injections, as the risk of intravascular injection is minimal. Aspirating the syringe can increase discomfort for the client and is not recommended for subcutaneous injections.

C) Use the Z-track method to administer the medication: The Z-track method is used for intramuscular injections to minimize medication leakage into the subcutaneous tissue. However, heparin is typically administered subcutaneously, and the Z-track method is not appropriate for this route of administration.

D) Gently massage the site following the injection: Massaging the site following a subcutaneous injection of heparin can increase the risk of bleeding and hematoma formation. Therefore, this action should be avoided to minimize bleeding at the injection site.

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Correct Answer is C

Explanation

A) Blood pressure: While monitoring blood pressure is important, assessing breath sounds takes priority after administering naloxone. Opioid toxicity can lead to respiratory depression, so ensuring adequate ventilation is crucial. Assessing breath sounds helps determine if the client's airway is clear and if ventilation has improved after naloxone administration.

B) Pain level: Pain assessment is important, but it is not the priority after administering naloxone for opioid toxicity. Respiratory status takes precedence due to the risk of respiratory depression associated with opioid overdose.

C) Breath sounds: This is the correct intervention. Naloxone reverses the effects of opioids, including respiratory depression. Assessing breath sounds allows the nurse to evaluate the client's respiratory status and determine the effectiveness of naloxone in improving ventilation.

D) Heart rate: Monitoring heart rate is important, but it is not the priority immediately after administering naloxone. Respiratory assessment takes precedence due to the risk of respiratory depression associated with opioid overdose.

A. "Pour expired medication tablets into a waste basket." B. "Return expired medication to the pharmacist." C. "Discard expired medication down the toilet." D. "Crush expired medication tablets and rinse them down the sink."

Correct Answer is B

Explanation

A) "Pour expire” medication tablets into a w“ste basket": This is an incorrect statement. Pourin” expired medication into a waste basket can pose a risk of accidental ingestion by children, pets, or individuals who may go through the trash. It is not a safe method of medication disposal.

B) "Return expired medication to the pharmac“st": This is the correct action for safe me”ication disposal. Many pharmacies have programs for the safe disposal of unused or expired medications. Returning medications to the pharmacist ensures proper disposal and prevents environmental contamination or misuse.

C) "Discard expired medication down the toil“t": This is an incorrect statement. Flushi”g medication down the toilet can contribute to water pollution and harm aquatic life. It is not recommended as a method of medication disposal unless specifically instructed for certain controlled substances by authorized entities.

D) "Crush expired medication tablets and rin“e them down the sink": This is an incorrect statement. Crushi”g medication tablets and rinsing them down the sink can introduce pharmaceuticals into the water supply, which can have adverse effects on aquatic ecosystems. It is not a safe or environmentally friendly method of disposal.

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A nu’se is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take to minimize bleeding following the injection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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