A nurse is preparing to administer heparin 250 units/kg subcutaneously to a client who weighs 150 lb. The heparin is available in a prefilled syringe containing 10,000 units/mL. How many mL should the nurse administer?

Choice A rationale

Inspiratory stridor reflects airway obstruction, potentially life-threatening following bronchoscopy. Causes include vocal cord edema or laryngospasm. Prompt intervention ensures airway patency and oxygenation. Audible stridor indicates urgent escalation.

Choice B rationale

Sore throat is anticipated due to irritation from the bronchoscope. This resolves without treatment, differentiating it from alarming symptoms like respiratory difficulty.

Choice C rationale

Post-bronchoscopy fever is common due to airway manipulation. Low-grade fever under 38.6°C does not necessitate urgent evaluation unless persistent or accompanied by other symptoms.

Choice D rationale

Bloody sputum results from mucosal trauma during the procedure. Minimal streaking is benign and resolves spontaneously. It does not indicate complications. .

Choice A rationale

Cutting the skin barrier opening 1/4 inch larger than the stoma prevents pressure on the stoma while ensuring a secure fit. This size accommodates natural stoma expansion during peristalsis, minimizes leakage, and reduces irritation to the peristomal skin.

Choice B rationale

Emptying the pouch when it is 1/3 to 1/2 full is recommended to prevent excessive weight, which can cause the adhesive barrier to loosen. Regular emptying maintains hygiene, reduces odors, and ensures comfort for the client, enhancing ostomy care.

Choice C rationale

Cleansing the skin surrounding the stoma with moisturizing soap is inappropriate as it leaves a residue that can interfere with the adhesive barrier's seal. Instead, non-moisturizing, residue-free cleansers are recommended to optimize ostomy barrier adhesion.

Choice D rationale

Using a standard enema set to irrigate the colostomy is not standard practice. Colostomy irrigation requires specialized equipment and careful technique to prevent mucosal trauma. Routine irrigation is typically advised for clients with specific medical conditions or stoma types.