A client has a prescription for heparin 1,000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?

Request a prescription to change the route of administration and use the available heparin.

Calculate and administer the equivalent dose of the available low molecular weight heparin.

Advise the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately.

Dilute the available heparin in 250 mL of normal saline solution prior to IV administration.

Answer and Explanation

The Correct Answer is C

A) Request a prescription to change the route of administration and use the available heparin:
Changing the route of administration without a prescription is not within the nurse's scope of practice and could lead to medication errors or adverse effects. It's essential to follow the prescribed route of administration to ensure patient safety.

B) Calculate and administer the equivalent dose of the available low molecular weight heparin:
Low molecular weight heparin (LMWH) has different dosing and potency compared to unfractionated heparin. Calculating an equivalent dose without a specific conversion ratio could result in under- or overdosing, leading to ineffective anticoagulation or increased risk of bleeding.

C) Advise the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately:
This is the correct action. Since the prescription specifies unfractionated heparin administered intravenously, the nurse should notify the pharmacy to provide the correct medication promptly. Using a different form of heparin could lead to dosing errors or ineffective treatment.

D) Dilute the available heparin in 250 mL of normal saline solution prior to IV administration:
This action is not appropriate because it assumes that the available heparin is suitable for intravenous administration, which may not be the case. Dilution may also alter the concentration and potency of the medication, leading to inaccurate dosing and potential adverse effects.

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Correct Answer is B

Explanation

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

A. Holds the pen in place after the injection. B. Administers into the fleshy outer thigh. C. Cleanses the injection pen for re-use. D. Inserts the injection pen through clothing.

Correct Answer is C

Explanation

A)Holds the pen in place after the injection:
This action is appropriate. Holding the auto-injector pen in place after administering the injection allows the medication to be fully delivered into the muscle. It ensures that the full dose of epinephrine is administered, which is crucial during an emergency situation such as anaphylaxis.

B) Administers into the fleshy outer thigh:
Administering the epinephrine injection into the fleshy outer thigh is the correct technique. The thigh muscle provides a large and accessible area for injection, allowing for rapid absorption of the medication into the bloodstream. This action facilitates the quick onset of epinephrine’s effects, which is vital in treating anaphylaxis.

C) Cleanses the injection pen for re-use:
This action requires intervention by the nurse. Epinephrine auto-injectors are designed for single use only and should not be cleansed or reused. Reusing the injection pen can lead to contamination, incorrect dosing, or malfunction, compromising its effectiveness during subsequent emergencies. It is essential to educate the client that the auto-injector pen is for one-time use only, and a new device should be used if another dose is required.

D) Inserts the injection pen through clothing:
While it is ideal to administer the injection directly onto bare skin, inserting the injection pen through clothing is acceptable in emergency situations when immediate access to bare skin is not possible. The priority during anaphylaxis is administering the epinephrine promptly. However, if feasible, the clothing should be moved aside to allow direct contact of the injection site with the skin for optimal absorption of the medication.

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A client has a prescription for heparin 1,000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client's medication drawer. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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