A client is to be started on a heparin intravenous infusion at 2,000 units per hour. On hand is an IV bag labeled 25,000 units/ 250 mL. At what rate (mL/hour) will the nurse set the pump? (Answer to the nearest whole number)

A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.

B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.

C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.

D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.

E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.

A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.

B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."

C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.

D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.