Question

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

administer the medication outside the 5-cm (2-in) radius of the umbilicus.
aspirate for blood return before injecting.
rub vigorously after the injection to promote absorption.
place a pressure dressing on the injection site to prevent bleeding.

Explanation:

Analyze the clinical scenario

The question asks for the correct action a nurse should plan to take when administering heparin subcutaneously. Heparin is a high-alert anticoagulant medication, and specific administration techniques must be followed to prevent tissue damage, hematoma formation, and bruising.

Evaluate the first option

Administering the medication outside the 5-cm (2-in) radius of the umbilicus is a standard clinical practice. The abdominal subcutaneous tissue is the preferred site for heparin injections, but the area immediately surrounding the umbilicus must be avoided to prevent accidental injection into umbilical blood vessels or deep fascial layers.

Evaluate the second option

Aspirating for blood return before injecting is contraindicated for subcutaneous heparin. Aspiration can cause tissue damage, rupture small capillaries, and lead to localized bleeding or hematoma formation at the injection site.

Evaluate the third option

Rubbing the site vigorously after injection is contraindicated. Massaging or rubbing the site can cause localized tissue trauma, rupture capillaries, and lead to bruising or hematoma formation due to the anticoagulant effect of heparin.

Evaluate the fourth option

Placing a pressure dressing is unnecessary for a routine subcutaneous injection. Gentle pressure with a sterile gauze pad for a few seconds is sufficient if there is minor bleeding, but a pressure dressing is not indicated.

Answer:

• (A) Administer the medication outside the 5-cm (2-in) radius of the umbilicus. (Correct answer)
• (B) Aspirate for blood return before injecting.
• (C) Rub vigorously after the injection to promote absorption.
• (D) Place a pressure dressing on the injection site to prevent bleeding.