A patient is ordered a heparin infusion at 1200 units/hour. Historically. IV heparin is premixed as 25.000 units of heparin in 250 mL NSS at the institution. Nurse A starts the infusion at 12 m/hr at 1700. The nurse asks their colleague to cosign the infusion for a prescribed rate change at 1900. Nurse B reminds Nurse A that there has been a recent pharmacy policy change. The V heparin that the patient is currently receiving is 50.000 units in 250 mL in NSS. Which of the following action(s)/statements) are accurate in this scenario?
(Select All that Apply.)
The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin m
After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin K
The nurses will complete an event report due to the medication error
Nurse A will document about the event report in the patients electronic medical record.
The patient has received a dose of heparin over the prescribed amount
The patient has received 3200 units of heparin from 1700-1900.
Correct Answer : C,E,F
A. The correct rate is 6 mL/hr
The correct calculation should be verified.
B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K
Protamine sulfate, not vitamin K, is the antidote for heparin.
C. The nurses will complete an event report due to the medication error
A medication error must be reported.
D. Nurse A will document about the event report in the patient’s EMR
Incident reports are internal documents and should not be documented in the EMR.
E. The patient has received a dose of heparin over the prescribed amount
Due to the increased concentration, the patient received more heparin than intended.
F. The patient has received 3200 units of heparin from 1700-1900.
This calculation confirms overdosing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.
B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.
C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.
D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.
E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.
Correct Answer is D
Explanation
A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.
B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.
C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.
D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.
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