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 B

Explanation

Choice A Reason:

Promoting activities that encourage self-reflection. While promoting self-reflection is important in the therapeutic process, it is not the most essential aspect initially for establishing a trusting nurse-patient relationship. Self-reflection activities are more effective once a foundation of trust has been established.

Choice B Reason:

Conveying an accepting attitude. This statement is correct. Conveying an accepting attitude is crucial in the initial stages of establishing a trusting nurse-patient relationship. Patients with borderline personality disorder often feel judged and misunderstood. An accepting attitude helps to create a safe and supportive environment, which is essential for building trust and encouraging open communication.

Choice C Reason:

Identifying community resources. Identifying community resources is important for long-term support and management of borderline personality disorder, but it is not the most essential aspect initially for establishing trust. This step is more relevant once the therapeutic relationship has been established and the patient is ready to engage with external support systems.

Choice D Reason:

Providing positive feedback. Providing positive feedback is beneficial in reinforcing positive behaviors and encouraging progress. However, it is not the most essential aspect initially for establishing trust. Positive feedback is more effective when the patient already feels understood and supported by the nurse.

A. Cardiac dysrhythmia resulting in cardiac arrest B. Endocrine imbalance causing amenorrhea C. Decreased metabolism causing cold intolerance D. Glucose intolerance resulting in hypoglycemia

Correct Answer is A

Explanation

a. Cardiac dysrhythmia resulting in cardiac arrest

Explanation of Choices

Choice A Reason: Cardiac Dysrhythmia Resulting in Cardiac Arrest

Cardiac dysrhythmias, or irregular heartbeats, are a significant health complication associated with anorexia nervosa. These dysrhythmias can result from electrolyte imbalances, particularly low potassium levels (hypokalemia), which are common in individuals with anorexia due to malnutrition and purging behaviors. Severe dysrhythmias can lead to cardiac arrest, making this one of the most critical and potentially fatal complications of anorexia nervosa. The heart muscle can weaken due to prolonged malnutrition, leading to a condition known as myocardial atrophy, which further increases the risk of cardiac complications.

Choice B Reason: Endocrine Imbalance Causing Amenorrhea

Amenorrhea, or the absence of menstruation, is a common endocrine complication in females with anorexia nervosa. This condition occurs due to the body’s response to severe weight loss and malnutrition, which disrupts the normal production of reproductive hormones. While amenorrhea is a significant health issue, it is not as immediately life-threatening as cardiac dysrhythmias. Amenorrhea can lead to long-term complications such as infertility and osteoporosis but does not typically result in acute medical emergencies.

Choice C Reason: Decreased Metabolism Causing Cold Intolerance

Decreased metabolism and cold intolerance are common symptoms in individuals with anorexia nervosa. The body reduces its metabolic rate in response to prolonged starvation to conserve energy. This can lead to a lower body temperature and increased sensitivity to cold. While uncomfortable and indicative of severe malnutrition, decreased metabolism and cold intolerance are not as immediately dangerous as cardiac dysrhythmias. These symptoms reflect the body’s adaptation to a state of energy deficiency but do not pose an immediate threat to life.

Choice D Reason: Glucose Intolerance Resulting in Hypoglycemia

Hypoglycemia, or low blood sugar, can occur in individuals with anorexia nervosa due to inadequate food intake. However, glucose intolerance and hypoglycemia are less common and less severe complications compared to cardiac dysrhythmias. Hypoglycemia can cause symptoms such as dizziness, confusion, and fainting, but it is typically manageable with appropriate nutritional support. It does not carry the same immediate risk of fatality as cardiac dysrhythmias.

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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

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Explanation

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Correct Answer is A

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.