A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis.

The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. What should be the infusion pump rate?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.