A client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

Request a prescription to change the route of administration and use the available heparin.

Calculate and administer the equivalent dose of the available low molecular weight heparin.

Dilute the available heparin in 250 ml of normal saline solution prior to IV administration.

Advise the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Requesting a prescription to change the route of administration and use the available heparin is not appropriate. Low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are not interchangeable on a unit-for-unit basis. They have different pharmacokinetics and dosing requirements. Changing the route without proper guidance can lead to incorrect dosing and potential complications.

Choice B reason:

Calculating and administering the equivalent dose of the available low molecular weight heparin is incorrect. LMWH and UFH have different dosing protocols and are not directly interchangeable. Administering LMWH instead of UFH without proper conversion and guidance can result in inappropriate anticoagulation.

Choice C reason:

Diluting the available heparin in 250 ml of normal saline solution prior to IV administration is not appropriate. The prescription specifies heparin 5000 units IV STAT, which indicates an immediate need for intravenous administration. Diluting and administering it in this manner does not align with the urgency of the order.

Choice D reason:

Advising the pharmacy of the need to deliver a vial of heparin to the nursing unit immediately is the correct action. This ensures that the client receives the prescribed medication in the correct form and dosage as ordered by the healthcare provider. It is crucial to follow the specific instructions for heparin administration to ensure patient safety and effective anticoagulation.

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Correct Answer is D

Explanation

Choice A reason:

Assessing for hypoglycemia between meals is important, but it is not the most critical intervention. Insulin lispro is a rapid-acting insulin that peaks quickly, so timing meals with insulin administration is crucial to prevent hypoglycemia.

Choice B reason:

Checking blood glucose levels every six hours is a good practice for monitoring overall glucose control, but it does not address the immediate need to coordinate insulin administration with meals to prevent hypoglycemia.

Choice C reason:

Keeping an oral liquid or glucose source available is essential for treating hypoglycemia if it occurs. However, the primary focus should be on preventing hypoglycemia by ensuring that meals are timed appropriately with insulin administration.

Choice D reason:

Providing meals at the same time insulin is given is the most important intervention. Insulin lispro acts rapidly, and if meals are not timed correctly, there is a high risk of hypoglycemia. Ensuring that the client eats at the same time as the insulin injection helps maintain stable blood glucose levels.

A. Apply warm compresses to legs. B. Monitor intake and output. C. Raise the head of the bed. D. Place on cardiac monitoring.

Correct Answer is D

Explanation

Choice A reason:

Applying warm compresses to the legs can help relieve muscle cramps, but it is not the most urgent intervention. Muscle cramps can be a sign of electrolyte imbalances, which are common side effects of furosemide. However, the presence of palpitations and tiredness suggests a more serious issue that needs immediate attention.

Choice B reason:

Monitoring intake and output is important for patients on furosemide to assess fluid balance and kidney function. However, this action does not address the immediate concern of potential cardiac issues indicated by palpitations and tiredness.

Choice C reason:

Raising the head of the bed can help alleviate respiratory symptoms such as a cough, but it does not address the potential cardiac complications. The presence of palpitations and tiredness suggests that cardiac monitoring is a higher priority.

Choice D reason:

Placing the client on cardiac monitoring is the most critical action. Furosemide can cause electrolyte imbalances, leading to arrhythmias and other cardiac issues. Given the symptoms of palpitations and tiredness, immediate cardiac monitoring is essential to detect and manage any potential life-threatening arrhythmias.

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A client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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