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 nurse is caring for a client receiving their second unit of Packed Red Blood Cells for an initial hemoglobin. The client appears flushed and complains of itching and urticaria. After following protocol (stopping transfusion, running 0.9% normal saline) and notifying the health care provider, the nurse would prepare to administer:

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?

The client presents with a complaint of "always dropping things and falling down." During the neurologic assessment, the nurse notices the client is unable to perform rapid alternating movements. Instead the client's response is very slow and misses often. What neurologic dysfunction would the nurse suspect?

The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is

The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?

The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:

The nurse is caring for a client, with no other pertinent medical history, who was burned over 709% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?