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 B

Explanation

A. While monitoring is important, doing nothing to address the hypoglycemia is not safe. A blood glucose level of 50 mg/dL is low and requires immediate intervention to prevent more severe hypoglycemic symptoms or complications.
B. This is a suitable option for treating mild to moderate hypoglycemia. Orange juice is a quick source of carbohydrates and can effectively raise blood glucose levels. Four ounces typically provides enough sugar to help increase the client's blood glucose level before dinner is served.
C. While this option would also effectively raise blood glucose, it is more complicated than simply having the client drink orange juice. The sugar may take additional time to dissolve, and grape juice may not be readily available. In an acute situation, simplicity and speed are key.
D. While hard candy can raise blood glucose levels, it may take longer to dissolve and provide sufficient glucose quickly compared to liquid sources like orange juice or grape juice. Additionally, the amount of candy needed may not be clear, making this a less reliable option in an urgent situation.

A. infectious agent and reservoir. B. portal of exit and mode of transmission. C. mode of transmission and portal of entry. D. susceptible host and infectious agent.

Correct Answer is C

Explanation

A. This option refers to the pathogens themselves (infectious agents) and the places where they live and multiply (reservoirs). Washing hands does not directly affect the relationship between these two.
B. The portal of exit refers to how an infectious agent leaves the reservoir (e.g., through feces, urine, etc.), and the mode of transmission refers to how the agent spreads (e.g., via hands, surfaces, etc.). Handwashing helps reduce the potential for pathogens to be transmitted but does not specifically break the chain between these two links.
C. Handwashing after using the bathroom effectively breaks the chain of infection by interrupting the mode of transmission (direct contact with contaminated hands) and preventing pathogens from entering another person's body (portal of entry). By cleaning hands, the risk of spreading infectious agents to others is significantly reduced.

D. This option refers to the relationship between a person who is vulnerable to infection (susceptible host) and the pathogens that cause disease (infectious agents). While handwashing helps prevent infections, it primarily acts on the transmission aspect rather than directly affecting susceptibility.

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Naxlex Comprehensive Predictor Exams

At 1630 a Type I diabetic client's blood glucose level is 50 mg/dl. The client is alert; however, dinner will not be served until 1715. The nurse's initial action should be to:

Correct Answer is B

Explanation

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:

Correct Answer is C

Explanation

The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?

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:

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)

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

A client who is to have an amputation of the lower extremity asks the nurse. "How much of my leg will the doctor have to amputate?" The nurse's response is based on the knowledge that the level of amputation is determined by the:

The nurse that which of the following activities/conditions increases complications of hypoglycemia for the individual with type 1 diabetes? (SELECT ALL THAT APPLY)

A client screened for diabetes has a fasting plasma glucose level of 120 mg/dl. The nurse will plan to teach the client about