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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Respiratory therapist: A respiratory therapist is essential in arranging home oxygen by evaluating the client’s respiratory needs, determining appropriate oxygen flow rates, and ensuring proper use of equipment. They also provide education on safety and maintenance, which is critical for clients newly diagnosed with COPD who must manage oxygen therapy at home.
B. Physical therapist: A physical therapist focuses on mobility and strength training, which can benefit clients with COPD but is not directly responsible for arranging or coordinating home oxygen therapy. Their role becomes more relevant after respiratory support is established and the client begins working on endurance and safe activity levels.
C. Social worker: A social worker assists with social support, financial resources, and coping needs but is not typically involved in arranging clinical respiratory equipment. Their involvement may be helpful later if the client requires community services, but they are not the primary referral for initiating oxygen therapy.
D. Case manager: A case manager plays a key role in long-term discharge planning and may eventually coordinate services, but the immediate need for oxygen setup requires a respiratory therapist’s specialized assessment. Once the respiratory plan is initiated, the case manager can support broader continuity of care needs.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. "Alternate the shoes you wear each day.": Rotating shoes helps prevent pressure points and reduces the risk of skin breakdown or foot ulcers, which is important for clients with diabetes who have impaired circulation and sensation.
B. "Apply synthetic fabric socks.": Synthetic or moisture-wicking socks help keep feet dry and prevent fungal infections, a common concern in clients with diabetes. Cotton or synthetic blends are preferred over thick wool or socks that retain moisture.
C. "Wear open-toe shoes": Open-toe shoes increase the risk of injury, infection, and trauma, which can lead to serious complications in diabetic clients. Closed, well-fitting shoes provide protection and support.
D. "Wash your feet daily with warm water and soap": Daily washing and gentle drying of the feet helps maintain hygiene, prevents infection, and allows early detection of cuts, cracks, or sores. Warm, not hot, water prevents burns in clients with neuropathy.
E. "Soak your feet for 1 hour each day.": Prolonged soaking can cause skin maceration, increasing the risk of infection and breakdown. Soaking is generally discouraged for clients with diabetes.
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