Difficulty: Medium
Average Score: 75%
Simulated
A nurse is preparing to administer subcutaneous heparin to a client. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A. When administering subcutaneous heparin, the nurse should insert the needle at least 5 cm (2 in) from the umbilicus to prevent any potential damage to underlying structures. This distance ensures proper absorption of the medication and reduces the risk of bruising or tissue damage. Massaging the site after administering the medication (choice B) is not recommended as it can increase the risk of bleeding and hematoma formation. Using a 21-gauge needle (choice C) is not a standard requirement for subcutaneous heparin administration. Aspirating before injecting the medication (choice D) is not necessary for subcutaneous injections as there are no large blood vessels in the subcutaneous tissue that could lead to inadvertent intravascular injection.