A client is to be started on a heparin intravenous infusion at 2,000 units per hour. On hand is an IV bag labeled 25,000 units/ 250 mL. At what rate (mL/hour) will the nurse set the pump? (Answer to the nearest whole number)

A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.

B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.

C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.

D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.

E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.

A) Hypersensitivity reaction: A hypersensitivity reaction typically involves an immune response where the body reacts to a substance as if it were harmful, leading to symptoms like rashes, swelling, or difficulty breathing. However, low hemoglobin and low white blood cell counts are not typical signs of a hypersensitivity reaction. This would involve more common allergic symptoms like itching or swelling, rather than hematologic changes.

B) Paradoxical reaction: A paradoxical reaction refers to when a medication causes an effect opposite to the expected result. For example, a sedative causing agitation instead of sleepiness. While a paradoxical reaction can involve unexpected effects, the hematologic changes (low hemoglobin and white blood cell counts) in this scenario do not align with this type of response.

C) Idiosyncratic reaction: An idiosyncratic reaction is an unusual or unexpected response to

a medication that is not related to the drug's pharmacologic properties or the dose given. It may be related to genetic factors or other individual differences in how a person metabolizes or responds to the drug. The low hemoglobin and low white blood cell counts in this case are unusual effects of diphenhydramine and suggest an idiosyncratic response, where the client’s body is reacting in an unexpected way to the medication.

D) Anti-cholinergic reaction: Anti-cholinergic reactions are typically related to symptoms caused by the blocking of acetylcholine, such as dry mouth, blurred vision, urinary retention, or constipation. While diphenhydramine has anti-cholinergic properties, the symptoms described (low hemoglobin and white blood cell counts) are not typical of an anti-cholinergic reaction.