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 skipping meals can affect blood glucose levels, it is not a direct primary cause of DKA. In some cases, if a person with Type 1 diabetes skips a meal and does not adjust their insulin accordingly, it could lead to hyperglycemia. However, the absence of insulin is the critical factor in DKA.
B. Gastrointestinal disturbances, such as vomiting or diarrhea, can contribute to DKA by leading to dehydration and altering insulin absorption. However, they are not primary causes. The main concern is that they may cause the individual to skip insulin or not manage their diabetes effectively.
C. DKA is primarily caused by a lack of insulin, which leads to the body breaking down fat for energy instead of glucose. This process produces ketones, which can accumulate and lead to acidosis. For individuals with Type 1 diabetes, consistently taking insulin is crucial to prevent DKA.
D. An insulin overdose can lead to hypoglycemia, not DKA. When too much insulin is taken, it can cause blood glucose levels to drop too low, which is the opposite of what occurs in DKA.

A. mental status = lethargic, oriented X 3 but unsure of reason for presenting for care B. arterial blood gas pH 7.47/ pCO2-40/HCO3-33/ pa02 = 95 C. arterial blood gas pH=7.31/pCO2-34/HCO3-17/pa02=98 D. heart rate=52, regular E. respiratory rate = 31, deep

Correct Answer is ["A","C","E"]

Explanation

A. Lethargy can occur in DKA due to the effects of hyperglycemia, acidosis, and dehydration. Even if the client is oriented, confusion about the reason for care suggests an altered mental state, which can be common in DKA.
B. This ABG indicates alkalosis (pH > 7.45), which is not typical for DKA. In DKA, we would expect a lower pH (acidosis). This set of values does not align with the expected clinical picture of DKA.
C. This ABG shows a pH of 7.31, indicating acidosis. The low HCO3 (17) supports metabolic acidosis, which is characteristic of DKA. This finding is consistent with the expected laboratory results in a patient experiencing DKA.
D. A heart rate of 52 (bradycardia) is not a common finding in DKA. In fact, tachycardia (elevated heart rate) is typically observed due to dehydration and compensatory mechanisms. Bradycardia would not be expected in this context.
E. A respiratory rate of 31, particularly if deep (known as Kussmaul respirations), is a classic sign of metabolic acidosis, including DKA. Kussmaul respirations are the body’s attempt to compensate for acidosis by increasing carbon dioxide elimination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

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.)

The nurse is teaching a client who is diagnosed with peripheral arterial disease about the benefits of walking to exercise. What information should the nurse reinforce with this client?

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?

The nurse is providing teaching to a client who is being discharged with a prescription for warfarin. Which information should be included in the teaching for this medication? (SELECT ALL THAT APPLY)

The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

A nurse is aware that which of the following social inequities are correlated with increased diabetes prevalence & more severe complications of diabetes? (SELECT ALL THAT APPLY)