Which nursing intervention(s) would be accurate when ...

[EAugust]

Which nursing intervention(s) would be accurate when administering heparin subcutaneously? (Select all that apply.)
 
  a. Assessment of recent aPTT levels
  b. Massaging the site after injection of medication
  c. Aspirating after needle insertion
  d. Documenting ecchymotic areas
  e. Monitoring of vital signs

Question 2

Which symptom is indicative of bleeding in a patient taking warfarin (Coumadin)?
 
  a. Bradycardia
  b. Petechiae
  c. Increased urinary output
  d. Dry skin

[recede]

Answer to Question 1

ANS: D, E
Ecchymosis, or bruising, indicates bleeding below the dermis and should be assessed closely. Patients on heparin therapy are prone to bleeding, which would lead to hemorrhagic shock. Vital sign alterations would alert the nurse to internal bleeding. aPTT levels are required to be monitored for the intravenous route, but not for subcutaneous injections. The injection site should not be massaged to reduce local bleeding. Aspiration may cause bruising when administering heparin subcutaneously.

Answer to Question 2

ANS: B
Petechiae are indicative of bleeding. These pinpoint red spots on the skin indicate intradermal hemorrhage. Bradycardia, increased urinary output, and dry skin are not indicative of bleeding.

[EAugust]

Gracias!

[bdobbins]

Excellent