A nurse is teaching an ACLS class and is discussing heart rhythms and treatment. Which of the following rhythms would indicate the need for defibrillation?

Choice A reason: Sodium level is not a direct measure of fluid volume. While sodium balance can influence fluid status, the serum sodium level can be affected by various factors and does not reliably indicate fluid volume increase on its own.

Choice B reason: Intake and output records are important for managing fluid balance, especially in a hospital setting. However, they can be influenced by many factors, such as incomplete recording or insensible losses, and do not provide a direct measure of fluid retention.

Choice C reason: Daily weight is considered the most reliable measure of fluid retention. Weight changes can reflect fluid balance accurately because 1 liter of fluid is roughly equivalent to 1 kilogram of body weight. In clients with chronic kidney disease, daily weight monitoring can help detect fluid volume increases or decreases promptly. For a client with chronic kidney disease, daily weight monitoring is a key assessment tool for detecting fluid volume changes. It provides a quantifiable and objective measure that can guide interventions to manage fluid balance effectively.

Choice D reason: Tissue turgor, which refers to the skin’s elasticity, is not a reliable measure of fluid volume. It can be influenced by age, edema, and other factors, and changes in turgor may not accurately reflect fluid status in the body.

- Step 1: Identify the prescribed dose in units per hour. The client is scheduled to receive 1,200 units/hr of heparin.

- Step 2: Identify the concentration of the available solution. The available solution contains 25,000 units of heparin in 500 mL D5W.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 25,000 units is to 500 mL as 1,200 units is to X mL.

- In other words, 25,000 units : 500 mL = 1,200 units : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 25,000 units × X mL = 1,200 units × 500 mL.

- Simplifying this gives us: 25,000X = 600,000.

- Dividing both sides by 25,000 gives us: X = 600,000 ÷ 25,000.

- Calculating the division gives us: X = 24.

Set the IV pump to deliver 24 mL/hr to administer the required dose of 1,200 units/hr.