A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?

Choice A rationale:

Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.

Choice B rationale:

Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.

Choice C rationale:

Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.

Choice D rationale:

Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.

Choice A rationale:

The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.

Choice B rationale:

Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.

Choice C rationale:

Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.

Choice D rationale:

Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.