The oncoming nurse sees that the patient is receiving IV heparin at 7 mL/hr. The concentration of the heparin is 50,000 units in 250 ml of saline. The patient is ordered 1600 units of heparin per hour. The lab calls the oncoming nurse with the result of the patient's activated partial prothrombin time (aPTT) is 37 seconds. What actions will the oncoming nurse take? (SELECT ALL THAT APPLY)

notify the prescriber about the current dose of heparin the patient is receiving

ask the nurse leaving to place a second IV & anticipate an order for IV 0.9 saline

assess the patient's site for manifestations of infiltration

read the pt's lab result back to the lab technician confirming the pt's name & date of birth

notify the prescriber & anticipate an order to give protamine sulfate

Answer and Explanation

Correct Answer : A,C

A.   The nurse should notify the prescriber about the current dose (7 mL/hr) because the patient is ordered 1600 units of heparin per hour. The current infusion rate needs to be assessed in relation to the aPTT result, especially if the aPTT indicates that the patient may be at risk for bleeding.
B.   While having a second IV may be useful for administering fluids or medications in case of a bleeding emergency, there is no immediate indication for IV 0.9 saline in this scenario. The priority is to assess the heparin dosage and aPTT before making additional IV arrangements.
C.   It’s important to assess the IV site for signs of infiltration, especially since the patient is on heparin therapy. Infiltration can affect the effectiveness of the medication and cause complications, so this assessment is vital.
D.   While it is important to verify lab results, the nurse should primarily focus on addressing the current situation regarding the heparin infusion and the patient’s anticoagulation status rather than confirming lab results with the lab technician at this moment.
E.   While protamine sulfate is an antidote to heparin, it is not warranted based solely on the aPTT result of 37 seconds. The normal aPTT range is typically around 30-40 seconds, depending on the laboratory standards, and the aPTT may not indicate that the patient requires reversal of heparin at this time.

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Correct Answer is C

Explanation

A. While positioning a patient prone can help with certain surgical recovery situations, it is not typically used immediately after an above-the-knee amputation. Additionally, elevating the arms may not provide any benefit and could cause discomfort.
B. This position can increase the risk of contractures in the residual limb, especially with an above-the- knee amputation. Keeping the stump flat may also lead to swelling and discomfort.
C. This position allows for proper elevation of the stump, which can help reduce swelling and promote healing. Supporting the stump on pillows prevents the risk of contractures and maintains the limb in a neutral position. It provides comfort and stability while facilitating blood flow.
D. While this position can help with venous return and reduce the risk of complications such as orthostatic hypotension, it is not specifically beneficial for an above-the-knee amputation recovery. It may not adequately address the need for proper stump support and elevation.

Correct Answer is ["6.2"]

Explanation

Total daily dose in mg:
1.5 grams/day = 1500 mg/day Dose per administration in mg:
1500 mg/day ÷ 3 doses/day = 500 mg/dose Volume to be administered per dose in mL:
(500 mg/dose) / (400 mg/5 mL) = 6.25 mL/dose
Rounding to the nearest tenth, the nurse will administer 6.2 mL per dose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has returned to the nursing unit from the post anesthesia care unit (PACU) 40 minutes ago following an above the knee amputation (AKA) of the right leg. In which position should the nurse place the client at this time?

Correct Answer is C

Explanation

A physician orders Lithium 5 grams/day is three divided doses PO for a client with bipolar disorder. The medication is supplied 400 mg/5 mL. How much will the nurse administer per dose? (Round the answer to the nearest tenth Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["6.2"]

Explanation

The nurse must give 25 micrograms of fentanyl IVP X 1 dose. Fentanyl is available in an ampule 100 micrograms per 2mL. How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

A 72-year-old client is admitted to the medical-surgical unit with a diagnosis of acute pyelonephritis. The client complains of costovertebral tenderness. What it the most appropriate nursing intervention?

The nurse is teaching an adult client with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

The nurse recognizes that teaching a client to wash the hands after using the bathroom is an attempt to break the chain of infection between the:

Your patient is prescribed Solu-Medrol 2 mg/kg/day in four divided doses. The medication is supplied as 10 mg/5 mL. The patient weighs 110 lbs. How many mL's will the nurse administer per dose?

A client receives 20 units of isophane insulin suspension (NPH) insulin at 0730. The nurse teaches the client that signs of hypoglycemia are most likely to occur at what time?

A client diagnosed with diabetes has severe peripheral neuropathy, resulting in numbness and reduced sensation. Which intervention should the nurse teach the client to prevent injury as a result of this complication?

A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it: