A client weighing 160 pounds is prescribed a heparin drip with an initial bolus of 60 units/kg IV, followed by a continuous infusion at 12 units/kg/hr. The available heparin concentration is 1,000 units/mL. What volume in milliliters should the nurse administer for the bolus, and what should the infusion pump flow rate be set at in mL/hr?
The Correct Answer is ["Bolus 4.36 mL"," infusion rate 0.87 mL\/hr"]
Step 1 is convert 160 pounds to kilograms: 160 lb ÷ 2.2 = 72.73 kg.
Step 2 is calculate the bolus dose: 72.73 kg × 60 units/kg = 4,363.8 units.
Step 3 is calculate bolus volume: 4,363.8 units ÷ 1,000 units/mL = 4.36 mL.
Step 4 is calculate infusion dose: 72.73 kg × 12 units/kg/hr = 872.76 units/hr.
Step 5 is calculate infusion rate: 872.76 units/hr ÷ 1,000 units/mL = 0.87 mL/hr. Final calculated answer: Bolus 4.36 mL, infusion rate 0.87 mL/hr.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This scenario involves a suspected anaphylactic reaction to intravenous penicillin. The nurse must apply the nursing process by prioritizing patient safety through immediate cessation of the offending agent, which prevents further exposure and systemic accumulation of the antigen causing the life-threatening respiratory and cardiovascular distress.
Choice A rationale
Stopping the infusion is the immediate priority action. This eliminates the source of the antigen that is triggering the systemic IgE-mediated allergic response, thereby preventing any further progression of the patient's anaphylactic symptoms, including airway obstruction and shock.
Choice B rationale
While auscultating breath sounds provides data on the patient's respiratory status, it does not address the cause of the distress. Delaying the discontinuation of the infusion to perform an assessment increases the risk of irreversible, fatal respiratory or cardiovascular collapse.
Choice C rationale
Elevating the head of the bed may assist with the patient's breathing, but it does not stop the underlying anaphylactic mechanism. This intervention is supportive rather than curative and cannot be prioritized over the removal of the allergen from circulation.
Choice D rationale
Notifying the healthcare provider is essential, but it must occur after the nurse has ensured the patient's safety by stopping the infusion. Following the notification, the provider will coordinate emergency management, including the administration of epinephrine to reverse the anaphylaxis.
Correct Answer is ["480"]
Explanation
Step 1 is convert 16 oz to mL using the conversion factor 1 oz equals 30 mL.
Step 2 is 16 oz × 30 mL/oz = 480 mL. Final calculated answer is 480 mL.
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