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 ["A","B","D"]

Explanation

Rationale:

A. Inability to concentrate: Hypoglycemia reduces glucose availability to the brain, leading to cognitive changes such as difficulty concentrating, confusion, or irritability. This neurologic symptom is an early and common indicator of low blood glucose.

B. Tremors: Trembling or shakiness occurs due to autonomic nervous system activation in response to low blood glucose. Catecholamine release stimulates muscle activity, making tremors a classic sign of hypoglycemia.

C. Acetone breath odor: Acetone or “fruity” breath is associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. It indicates fat metabolism due to insulin deficiency, not low blood glucose.

D. Diaphoresis: Profuse sweating is a sympathetic nervous system response to hypoglycemia. It often accompanies other adrenergic symptoms such as palpitations, anxiety, and tremors, signaling low blood sugar.

E. Polydipsia: Excessive thirst is a symptom of hyperglycemia and is not associated with hypoglycemia. It occurs when high blood glucose leads to osmotic diuresis and fluid loss.

A. A client who has dementia B. A client who has osteoarthritis C. A client who has cystic fibrosis D. A client who has chronic hypertension

Correct Answer is C

Explanation

Rationale:

A. A client who has dementia: Dementia affects cognitive function but does not inherently increase susceptibility to respiratory complications from mold exposure. While general health monitoring is important, this client is not at high risk for mold-related adverse effects.

B. A client who has osteoarthritis: Osteoarthritis primarily affects joints and mobility. It does not compromise the respiratory system or immune response in a way that would increase vulnerability to mold exposure.

C. A client who has cystic fibrosis: Clients with cystic fibrosis have impaired mucociliary clearance and chronic respiratory vulnerability, making them more susceptible to respiratory infections and complications from environmental mold exposure. Mold inhalation can exacerbate pulmonary symptoms and lead to significant health risks.

D. A client who has chronic hypertension: Hypertension affects the cardiovascular system but does not directly increase susceptibility to respiratory complications from mold. This client is not considered high risk for adverse effects from mold exposure.

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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 caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is C

Explanation

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