A nurse is caring for a client who is receiving heparin 3,800 units subcutaneously daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer? Round to thenearesttenth

A. Furosemide 10mg IV bolus every 12 hours:

Furosemide is a loop diuretic commonly used in heart failure management to reduce fluid overload. The prescribed dose of 10 mg IV bolus every 12 hours is within the typical range for furosemide administration in acute heart failure.

B. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain:

Morphine sulfate is often used in the management of acute pain, including pain associated with myocardial infarction. The prescribed dose of 2 mg IV bolus every 2 hours PRN for pain is appropriate and aligns with standard pain management protocols.

C. Laboratory testing of serum potassium upon admission:

It is common practice to perform laboratory testing, including serum potassium levels, upon admission for clients with acute heart failure, especially if they are receiving diuretics or other medications that can affect electrolyte balance. This prescription is appropriate and necessary for monitoring the client's condition.

D. 0.9% normal saline IV at 150 mL/hr continuous:

This prescription raises a concern because administering 0.9% normal saline at a rate of 150 mL/hr continuously may lead to fluid overload in a client with acute heart failure. The rate of IV fluid administration should be carefully assessed based on the client's fluid status, renal function, and hemodynamic parameters to avoid exacerbating heart failure symptoms.

A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.

B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.

C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.

D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.