a nurse is preparing to administer heparin subcutaneously to a client which of the following actions should the nurse take

ATI RN

ATI Exit Exam

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

A. Use a 21-gauge needle for injection.
B. Inject the medication into the client's deltoid muscle.
C. Administer the medication within 5 cm (2 in) of the umbilicus.
D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

2. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A. I can give you information about respite care if you are interested.
B. You should consider taking a sleeping pill before bed each night.
C. It must be difficult taking care of someone who is terminally ill.
D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

3. What is the priority intervention for a patient with dehydration?

A. Administer IV fluids
B. Monitor intake and output
C. Administer oral fluids
D. Provide electrolyte replacement

Correct answer: A

Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.

4. What is the best intervention for a patient experiencing hypoxia?

A. Administer oxygen
B. Reposition the patient
C. Provide humidified air
D. Provide chest physiotherapy

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

5. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?

A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).