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.)

Answer and Explanation

The Correct Answer is ["8"]

Step 1 is: Calculate the total units of heparin in the bag, which is 25,000 units.

Step 2 is: Divide the total units by the total volume to find the units per mL, which is (25,000 units ÷ 250 mL) = 100 units/mL.

Step 3 is: Divide the desired units per hour by the units per mL to find the mL/hr, which is (800 units/hr ÷ 100 units/mL) = 8 mL/hr. So, the infusion pump rate should be set at 8 mL/hr.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.

Choice B rationale

The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.

Choice C rationale

The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.

Choice D rationale

The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.

A. Place a pillow under the patient’s knees. B. Position a trochanter roll under each of the patient’s hips. C. Advise the patient to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the patient’s feet.

Correct Answer is D

Explanation

Choice A rationale

Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.

Choice B rationale

Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.

Choice C rationale

Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.

Choice D rationale

Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.Which three findings require follow-up?

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?

Correct Answer is D

Explanation

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