A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?
Complete an incident report.
Check the client for indications of bleeding.
Monitor the client's aPTT levels
Notify the risk manager.
The Correct Answer is B
Choice A reason:
Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.
Choice B reason:
Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.
After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.
Choice C reason:
Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.
Choice D reason:
Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and explanation.
The correct answer is choice C, hypertension. Hypertension is a contraindication to living kidney donation because it can increase the risk of kidney disease and cardiovascular complications in the donor. Hypertension can also affect the quality and survival of the donated kidney in the recipient.
Therefore, a potential donor with uncontrolled or poorly controlled hypertension should not undergo nephrectomy.
Choice A, osteoarthritis, is not a contraindication to living kidney donation.
Osteoarthritis is a degenerative joint disease that does not affect the kidneys or the cardiovascular system.
It may cause pain and stiffness in the joints, but it can be managed with medications and physical therapy. A potential donor with osteoarthritis can donate a kidney if they have normal kidney function and no other medical problems.
Choice B, primary glaucoma, is not a contraindication to living kidney donation.
Primary glaucoma is a condition that causes increased pressure in the eye and can lead to vision loss if untreated.
It does not affect the kidneys or the cardiovascular system. A potential donor with primary glaucoma can donate a kidney if they have normal kidney function and no other medical problems.
Choice D, amputation, is not a contraindication to living kidney donation.
Amputation is the surgical removal of a limb or part of a limb due to injury, infection, or disease.
It does not affect the kidneys or the cardiovascular system. A potential donor with amputation can donate a kidney if they have normal kidney function and no other medical problems.
Normal ranges for blood pressure are less than 120/80 mmHg for systolic and diastolic pressure, respectively.
Normal ranges for kidney function are eGFR above 60 mL/min/1.73 m2 and albuminuria below 30 mg/g.
Correct Answer is C
Explanation
The correct answer is choice C. Perform the procedure prior to meals.
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.
If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.
Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.
A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
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