A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS.

Calculate the rate at which the nurse should set the infusion pump.

Answer and Explanation

The Correct Answer is ["5"]

Step 1: Determine the concentration of Heparin in units per mL. 25,000 units ÷ 250 mL = 100 units per mL Result: 100

Step 2: Determine the rate in mL per hour needed to deliver 500 units per hour. 500 units ÷ 100 units per mL = 5 mL per hour Result: 5 mL per hour

The nurse should set the infusion pump to deliver at a rate of 5 mL per hour.

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Correct Answer is C

Explanation

The correct answer is c. Be consistent in staff limit setting.

Choice A Reason: Provide Positive Reinforcement for Acting-Out Behavior

Providing positive reinforcement for acting-out behavior is counterproductive, especially for clients with antisocial personality disorder (ASPD). Positive reinforcement would encourage the continuation of manipulative and disruptive behaviors, which are characteristic of ASPD. Instead, interventions should focus on promoting positive behaviors and discouraging negative ones.

Choice B Reason: Discourage the Client from Discussing Feelings of Fear and Inferiority

Discouraging clients from discussing their feelings is not a therapeutic approach. Clients with ASPD may have underlying issues that contribute to their behavior, and discussing these feelings can be an important part of therapy. Open communication can help in understanding the root causes of their behavior and developing effective treatment plans.

Choice C Reason: Be Consistent in Staff Limit Setting

Consistency in staff limit setting is crucial when dealing with clients with ASPD. These individuals often test boundaries and manipulate situations to their advantage. Consistent limit setting helps establish clear expectations and consequences, which can reduce manipulative behaviors and promote a more structured environment4. This approach helps clients understand that their actions have predictable outcomes, which is essential for behavior modification.

Choice D Reason: Ignore, Rather than Confront Inappropriate Behavior

Ignoring inappropriate behavior can lead to an escalation of such behaviors. Clients with ASPD may interpret this as a lack of consequences, reinforcing their manipulative actions. Confronting inappropriate behavior in a consistent and structured manner is necessary to address and modify these behaviors effectively.

A. Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings. B. Play cards with 3 patients during unstructured time. C. Review follow-up care with a patient about to be discharged. D. Set a goal for the day for a patient with a borderline personality disorder. E. Obtain a weight on a patient with bipolar disorder in a hypomanic state.

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

Explanation

Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings

This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.

Choice B Reason: Play cards with 3 patients during unstructured time

This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.

Choice C Reason: Review follow-up care with a patient about to be discharged

This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.

Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder

This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.

Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state

This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.

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A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS. Calculate the rate at which the nurse should set the infusion pump.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

Correct Answer is C

Explanation

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

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

Explanation

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A client is to receive a continuous Heparin infusion at s00 units per hour. Pharmacy supplies Heparin in a concentration of 25,000 units per 250mL of NSS.

Calculate the rate at which the nurse should set the infusion pump.