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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)

Answer and Explanation

The Correct Answer is ["20"]

Identify the total units of heparin in the bag:

The IV bag contains 25,000 units of heparin in 250 mL.

Identify the desired hourly dose:

The client is ordered to receive 2,000 units of heparin per hour.

Calculate the mL containing 2,000 units:

We can set up a proportion:

(25,000 units) / (250 mL) = (2,000 units) / (x mL)

Solving for x, we get:

x = (2,000 units x 250 mL) / 25,000 units x = 20 mL

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Correct Answer is B

Explanation

A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.

B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.

C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.

D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.

E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.

A. 50 B. 100 C. 25 D. 75

Correct Answer is C

Explanation

Here’s the step-by-step process:

After the first half-life (1 half-life), 50% of the initial drug is left.

200 mg → 100 mg (half is eliminated, 100 mg remains).

After the second half-life (2 half-lives), 50% of the remaining drug is eliminated again.

100 mg → 50 mg (half of 100 mg is eliminated, 50 mg remains).

After the third half-life (3 half-lives), 50% of the remaining drug is eliminated again.

50 mg → 25 mg (half of 50 mg is eliminated, 25 mg remains).

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?

Correct Answer is B

Explanation

The client receives one dose of 200 mg of a medication. How much drug is in the body at 3 half-lives?

Correct Answer is C

Explanation

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