A client reports, “I have not had a bowel movement in 4 days and I have vomited once or twice.”. Given the client’s cardiovascular and gastrointestinal status, and social history, what should the nurse plan to do first?

Step 1: Identify the order. The order is for 15,000 units of heparin.

Step 2: Identify the available medication. The available medication is heparin 10,000 units/mL.

Step 3: Calculate the dose. To find out how many mL to administer, divide the number of units ordered by the number of units per mL. So, 15,000 units ÷ 10,000 units/mL = 1.5 mL. So, the nurse should administer 1.5 mL of heparin with each dose.

Choice A rationale: The abdominal findings require follow-up. The client reports mild abdominal pain, rating it as 7 on a scale of 0 to 10, and states they haven’t had a bowel movement in 4 days. Additionally, the physical exam reveals tenderness to palpation and high-pitched bowel sounds in the gastrointestinal area. The CT scan indicates an obstruction in the small intestine, as evidenced by distention with fluid and gas in the small intestine and the absence of gas in the colon. These symptoms suggest a significant gastrointestinal issue that needs further evaluation and management.

Choice B rationale: The BUN level also requires follow-up. The BUN level is elevated at 25 mg/dL, which is above the normal range of 10 to 20 mg/dL. This could indicate dehydration or kidney dysfunction, especially in the context of the client’s symptoms and dry mucous membranes. Elevated BUN levels can be caused by a high-protein diet, dehydration, certain medications, and a variety of medical conditions, including kidney disease.

Choice C rationale: The blood pressure requires follow-up. The client’s blood pressure is low at 92/60 mm Hg. This, combined with an elevated pulse of 106/min, could indicate hypovolemia or dehydration, especially given the client’s vomiting and lack of bowel movements. Hypovolemia refers to a decrease in the volume of blood in the body, which can be caused by a variety of conditions, including dehydration, severe burns, and excessive sweating. Hypovolemia can lead to hypotension (low blood pressure).

Choice D rationale: The breath sounds do not require follow-up. The respiratory examination reveals bilateral breath sounds clear, which is within the normal range. Clear breath sounds indicate that air is flowing smoothly through the bronchial tubes and lungs without obstruction, which is a positive sign.

Choice E rationale: The WBC count does not require follow-up. The WBC count is 9,000/mm, which is within the normal range of 5,000 to

Choice F rationale. Potassium level: The potassium level is low at 3.3 mEq/L (normal range: 3.5 to 5 mEq/L), which can be concerning and may need correction to prevent complications such as cardiac arrhythmias.