A nurse is caring for a client with acute coronary syndrome.

The client is ordered weight based heparin.

The order reads, "Give Heparin bolus 60 units/kg IV push now.”. The nurse notes the client's weight is 231 pounds.

How many units of heparin will the nurse give for the bolus?

Choice A rationale

An elevated ST segment on an EKG is typically indicative of myocardial ischemia or injury, such as an acute myocardial infarction. While ESRD clients are at higher risk for cardiac issues, an elevated ST segment is not a direct or primary sign of hyperkalemia. Hyperkalemia primarily affects repolarization and conduction.

Choice B rationale

Peaked T waves are a classic and early electrocardiographic sign of hyperkalemia. This occurs due to the rapid repolarization of ventricular myocardial cells caused by the high extracellular potassium concentration. This alteration in potassium gradients affects the efflux of potassium during repolarization, leading to the characteristic tall, narrow, and peaked T waves. The normal range for serum potassium is 3.5 to 5.0 mEq/L.

Choice C rationale

A prolonged PR interval indicates a delay in atrioventricular conduction. While severe hyperkalemia can eventually lead to conduction disturbances, a prolonged PR interval is not one of the earliest or most specific signs of hyperkalemia. Other conditions like AV blocks or certain medications are more commonly associated with this finding.

Choice D rationale

An inverted P wave suggests an abnormal atrial depolarization sequence, potentially originating from a different part of the atria or a junctional rhythm. While electrolyte imbalances can affect cardiac rhythm, an inverted P wave is not a characteristic EKG finding directly associated with hyperkalemia. Hyperkalemia's primary effect on P waves is usually diminution or disappearance.

Choice A rationale

A review of chest x-ray is primarily used to assess pulmonary status or thoracic aortic issues. While a client with an AAA may have concurrent cardiopulmonary conditions, it is not the immediate priority for an abdominal aneurysm where rupture risk is a significant concern.

Choice B rationale

Assessment of blood pressure is the priority because uncontrolled hypertension is a major risk factor for abdominal aortic aneurysm expansion and rupture. Monitoring blood pressure allows for timely intervention to reduce arterial wall stress and prevent a life-threatening event. A normal range is 120/80 mm Hg.

Choice C rationale

Deep palpation of the abdomen is contraindicated in a client with a known abdominal aortic aneurysm due to the significant risk of aneurysm rupture. Palpation can increase intra-abdominal pressure or directly stress the weakened aortic wall, potentially leading to a catastrophic hemorrhage.

Choice D rationale

Assessing the client's pain is important for comfort and to identify potential complications, but it is not the immediate priority over monitoring for signs of rupture. While severe abdominal or back pain can indicate an impending rupture, direct physiological parameters like blood pressure are more critical for immediate risk assessment.