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 C
Explanation
Rationale:
A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.
B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.
C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.
D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.
Correct Answer is C
Explanation
Rationale:
A. Metoclopramide: Metoclopramide is an antiemetic and prokinetic agent used to treat nausea and gastroparesis. It is not classified as a controlled substance because it does not have potential for abuse or dependence.
B. Dantrolene: Dantrolene is a muscle relaxant used to treat spasticity and malignant hyperthermia. It is not a controlled substance as it has low potential for abuse or addiction.
C. Midazolam: Midazolam is a benzodiazepine used for sedation, anesthesia, and seizure management. Benzodiazepines are classified as controlled substances due to their potential for dependence, abuse, and misuse, making midazolam a controlled drug.
D. Ketorolac: Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used for short-term pain management. It is not a controlled substance because it has minimal risk for abuse or dependence.
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