A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solution is "Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL". The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Rationale for correct choices:

• Pain: The client reports a pain level of 10/10 in the left arm, described as sharp and constant. Pain at this severity requires urgent management because uncontrolled pain can impair mobility. Immediate intervention for pain ensures comfort and supports further diagnostic and therapeutic procedures.

• Compartment syndrome: Findings of swelling, decreased sensation, coolness of the skin, and diminished left radial pulse suggest compromised circulation. These are classic warning signs of compartment syndrome, a limb-threatening complication caused by increased pressure within a muscle compartment.

Rationale for incorrect choices:

• Mobility: While the client’s long-term recovery will require mobility interventions, it is not the immediate priority in the acute emergency setting. Pain and neurovascular compromise take precedence over mobility at this stage because they directly affect safety and circulation.

• Swelling: Swelling is a significant concern, but it is a symptom rather than the priority need. Addressing pain and preventing complications such as compartment syndrome will indirectly reduce swelling by improving circulation and managing tissue injury.

• Venous thromboembolism: The client’s high BMI and reduced mobility put him at risk for VTE, but this is a longer-term complication. It does not outweigh the immediate need to manage severe pain and monitor for compartment syndrome, which can cause rapid tissue necrosis.

• Fat embolism syndrome: Fat embolism is a possible complication of long bone fractures, but there is no evidence here of a femoral fracture or respiratory distress. Although his weight and orthopedic history are risk factors, the current findings point more strongly toward compartment syndrome.

A. Position the client's head facing away from the site: While positioning can help reduce the risk of infection or discomfort, it does not ensure that the catheter is patent or safe for medication administration.

B. Aspirate for the presence of a blood return: Confirming blood return verifies that the central venous catheter is patent and correctly positioned in the bloodstream. This is a critical safety step before administering intravenous medications to prevent extravasation or ineffective delivery.

C. Prepare a saline flush in a three mL syringe: While flushing the catheter is important for maintaining patency, the nurse must first confirm the catheter is patent by aspirating for blood return before flushing or administering medication.

D. Initiate an infusion of 0.9% normal saline solution: Starting a continuous infusion is not necessary solely for medication administration. The priority is confirming patency and safe access, after which flushing and medication administration can proceed.