ATI Exit Exam Related

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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.