A nurse is caring for a client who received 50, 000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

Check the client for indications of bleeding

Monitor the client's aPTT levels

Complete an incident report.

Notify the risk manager.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Check the client for indications of bleeding: The priority action following a heparin overdose is to assess the client for signs of active or internal bleeding, such as hematuria, melena, bruising, or hypotension. Immediate assessment guides urgent interventions to prevent life-threatening complications.

B. Monitor the client's aPTT levels: Monitoring aPTT is important to evaluate the anticoagulant effect and guide treatment, but it is secondary to assessing for actual bleeding. Assessment of clinical signs takes precedence over laboratory monitoring in urgent situations.

C. Complete an incident report: Documenting the medication error is necessary for legal and quality improvement purposes, but it is not the first action. Patient safety and immediate clinical assessment come before reporting.

D. Notify the risk manager: Informing the risk manager is part of the incident reporting process, but addressing the client’s immediate safety needs comes first. Notification can occur after urgent assessment and stabilization.

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Correct Answer is C

Explanation

Rationale:

A. Change a dressing on an implanted central venous access device: This is a sterile procedure that requires assessment skills and knowledge of infection control. It must be performed by a licensed nurse, not an assistive personnel (AP).

B. Suction a new tracheostomy: Suctioning a new tracheostomy is a high-risk procedure requiring specialized knowledge to prevent hypoxia or trauma. Only a licensed nurse should perform this intervention.

C. Perform postmortem care: Postmortem care is within the scope of practice for an AP. It involves cleansing, positioning, and preparing the body for the family or mortuary, and does not require advanced clinical judgment or sterile technique.

D. Remove an NG tube: Removal of a nasogastric tube requires assessment and understanding of client tolerance and potential complications, which are responsibilities of a licensed nurse. It is not appropriate to delegate this task to an AP.

A. Instruct the client to carry the newborn in their arms when going to the nursery. B. Remove the electronic security sensor when the newborn is in the client's room. C. Apply identification bands after the newborn's first bath. D. Discourage family from posting photos of the newborn on social media.

Correct Answer is D

Explanation

Rationale:

A. Instruct the client to carry the newborn in their arms when going to the nursery: Carrying a newborn to the nursery without security measures increases the risk of abduction. Infants should always be transported in a secure bassinet or by authorized staff using the hospital’s safety protocols.

B. Remove the electronic security sensor when the newborn is in the client's room: The electronic security sensor is essential for monitoring the newborn’s location within the hospital. Removing it defeats the purpose of the abduction prevention system and is unsafe.

C. Apply identification bands after the newborn's first bath: Identification bands should be applied immediately after birth to ensure accurate identification from the start. Waiting until after the first bath delays verification and increases risk for misidentification or abduction.

D. Discourage family from posting photos of the newborn on social media: Sharing identifiable information or images online can inadvertently alert potential abductors to the newborn’s presence. Families should be advised to limit social media exposure until the infant’s safety can be ensured.

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A nurse is caring for a client who received 50, 000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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