The doctor orders your patient to start an IV Heparin drip at 16 units/kg/hr and to administer a loading bolus dose of 60 units/kg IV before initiation of the drip. You're supplied with a Heparin bag that reads 12,500 units/250 mL. The patient weighs 198 lbs. What is the flow rate you will set the IV pump (mL/hr)?

A. Call the Rapid Response Teamis correct because the client is exhibiting life-threatening signs of deterioration. A respiratory rate of 10 breaths per minute indicates bradypnea, which can lead to hypoxia and respiratory failure if not addressed immediately. The tachycardia (pulse 136) reflects the body’s attempt to compensate for hypotension and maintain perfusion. A blood pressure of 92/78 mm Hg is borderline low and may worsen, leading to inadequate organ perfusion. The altered level of consciousness, responding only to voice, suggests decreased cerebral perfusion, a critical warning sign. These findings collectively indicate the client is in early to moderate shockand requires immediate bedside evaluation and interventionto prevent progression to irreversible shock. The Rapid Response Team brings skilled personnel and resources to stabilize the client quickly, including interventions such as airway support, intravenous fluids, and medication administration.

B. Transfer the client to the Intensive Care Unitis incorrect because while ICU care may ultimately be necessary, immediate stabilization is the priority. Rapid Response activation allows critical interventions to occur at the bedside before transfer, reducing the risk of further deterioration during transport.

C. Continue monitoring every 30 minutesis incorrect because the client’s current vital signs indicate acute instability. Waiting 30 minutes could result in respiratory failure, shock progression, or cardiac arrest. Continuous monitoring alone is insufficient.

D. Notify the unit charge nurse immediatelyis incorrect because while the charge nurse should be informed, this action does not ensure prompt bedside interventionby personnel trained to manage acute life-threatening changes. The Rapid Response Team is the recommended mechanism for urgent evaluation and treatment.

A. Retractions or depressions between ribs usually indicate increased work of breathing, but they are not specific for tension pneumothoraxand do not involve tracheal deviation or mediastinal shift.

B. Hyperresonance is typically percussed on the side with trapped air(the affected side), not the unaffected side. Hyperresonance alone does not confirm a tension pneumothorax.

C. Rales (crackles) are associated with fluid in the alveoli, such as in pneumonia or pulmonary edema. Tension pneumothorax involves air in the pleural space, not fluid, so rales are not expected.

D. In tension pneumothorax, air accumulates under pressure in the pleural space, compressing the lung and pushing the mediastinum, including the trachea, toward the unaffected side. This is a classic and life-threatening signthat requires immediate decompression.