A nurse is caring for a client who has been admitted to the antepartum unit

Exhibits

Complete the following sentence by using the list of options. Separate the two answers using a comma.

The nurse should recognize the client is experiencing

due to

.

The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.

Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.

Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.

Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.