The physician has ordered heparin 7000 units subcutaneous daily.

The medication is supplied in heparin 10,000 units in 1 mL. How many milliliters will the nurse administer?

Choice A rationale

Impaired gas exchange directly affects the patient's oxygenation and carbon dioxide elimination, which are fundamental physiological needs. Alveolar inflammation and infection in pneumonia disrupt the normal diffusion of gases in the lungs, potentially leading to hypoxemia and hypercapnia, posing an immediate threat to life if not addressed promptly. Normal partial pressure of oxygen (PaO₂) is 80-100 mmHg, and normal partial pressure of carbon dioxide (PaCO₂) is 35-45 mmHg.

Choice B rationale

Pruritus, or itching, while uncomfortable, is a symptom related to medication side effects and does not directly compromise vital physiological functions like gas exchange. Addressing the underlying cause and providing symptomatic relief are important but are a lower priority than ensuring adequate oxygenation.

Choice C rationale

Knowledge deficit regarding risk factors for pneumonia is important for long-term health management and prevention of future episodes. However, in the acute phase of pneumonia, the immediate physiological compromise of impaired gas exchange takes precedence over addressing knowledge gaps.

Choice D rationale

Activity intolerance due to fatigue and shortness of breath is a consequence of the physiological changes associated with pneumonia, primarily the impaired gas exchange. While it affects the patient's quality of life, it is a manifestation of the primary problem rather than the most immediate threat to physiological stability.

Choice A rationale

While physician involvement may be necessary in some cases depending on hospital policy, the nurse's immediate action should be to follow established protocols regarding medical record access. Directly stating the doctor's permission is needed might not be universally true.

Choice B rationale

While patient medical records are confidential, direct denial of access to a family member without checking hospital policy or consulting a supervisor may not be the appropriate first response. There might be specific guidelines regarding family access.

Choice C rationale

Asking the supervisor is the most appropriate initial response. It allows the nurse to adhere to hospital policy and legal guidelines regarding patient privacy and medical record access, ensuring compliance and proper procedure.

Choice D rationale

Allowing the daughter to immediately view the record without verifying hospital policy could lead to a breach of confidentiality or violation of regulations regarding access to protected health information.