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

Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds such as crackles.

Choice B rationale

While measuring urine output is important to assess kidney function and fluid balance, it is not the priority in this case.

Choice C rationale

Monitoring blood pressure readings is important when administering IV fluids, but it is not the priority in this case.

Choice D rationale

Monitoring electrolyte levels is important when administering IV fluids, but it is not the priority in this case.

Choice A rationale

A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.

Choice B rationale

The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.

Choice C rationale

The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.

Choice D rationale

The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.