A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

24-hour intake at the current infusion rate.

Serum potassium level of 3.1 mEq/L (3.1 mmol/L).

Gastric output of 900 mL in the last 24 hours.

Increased blood urea nitrogen (BUN).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.

Correct Answer is ["30"]

Explanation

The correct answer is 30 mL/hour.

Step 1 is to calculate the total amount of norepinephrine in the IV bag: 4 mg norepinephrine ÷ 1000 mL = 0.004 mg/mL

Step 2 is to convert the patient's weight from pounds to kilograms: 176 pounds ÷ 2.2 = 80 kilograms

Step 3 is to calculate the total amount of norepinephrine the patient will receive per minute: 2 mcg/min × 60 min = 120 mcg/min

Step 4 is to convert micrograms (mcg) to milligrams (mg): 120 mcg ÷ 1000 = 0.12 mg

Step 5 is to calculate the total volume of norepinephrine needed per hour: 0.12 mg ÷ 0.004 mg/mL = 30 mL/hour

Therefore, the nurse should program the infusion pump to deliver 30 mL/hour.

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D;W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

Correct Answer is ["30"]

Explanation

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