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?

Rationale:

A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: Severe pain is significant and requires timely management, but it is not immediately life-threatening compared to acute cardiac events. Pain control should follow stabilization of critical conditions.

B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates a possible acute myocardial infarction, which is a life-threatening emergency. Prompt assessment and intervention are crucial to prevent cardiac damage or death, making this the highest priority.

C. A client who has Clostridium difficile and a temperature of 38.5°C (101.5°F): Fever and infection require attention, but this client is currently stable compared with someone experiencing an acute myocardial infarction. Infection control and monitoring can follow stabilization of higher-priority emergencies.

D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: These findings indicate fluid imbalance and cardiovascular compromise, but they are not as immediately life-threatening as an acute STEMI. Monitoring and management should follow urgent cardiac care.

Rationale for correct choices

• Neurological: Reports that dizziness and palpitations started 2 months ago: Persistent dizziness and palpitations may indicate arrhythmias, decreased cardiac output, or early cardiovascular compromise. Although the client is alert and oriented, these symptoms suggest insufficient cerebral perfusion or possible underlying cardiac pathology that requires further evaluation.

• Cardiovascular: Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally, Capillary refill time 5 seconds for all extremities: Diminished pulses, mild edema, and prolonged capillary refill time indicate potential peripheral arterial insufficiency and early signs of fluid overload or heart failure. These findings suggest impaired circulation and warrant further assessment.

• Respiratory: Fatigue and dyspnea with exertion started 1 week ago: New-onset exertional dyspnea and fatigue may be early indicators of compromised cardiac or pulmonary function. Despite clear lung sounds, these symptoms suggest reduced oxygen delivery or early heart failure. Prompt evaluation is required to prevent progression and to identify reversible causes.

• Vital Signs: Heart rate 105/min, Blood pressure 164/92 mm Hg: Tachycardia and hypertension indicate increased cardiac workload and potential risk for end-organ damage. Persistent elevated BP above 140/90 mm Hg is associated with cardiovascular complications, including left ventricular hypertrophy and renal impairment. Monitoring and further evaluation of cardiac function, lifestyle factors, and medication adherence are necessary.

Rationale for incorrect choices

• Neurological: Alert and oriented to person, place, and time: Being alert and oriented reflects intact cognitive function and does not require immediate further evaluation. While neurological changes may arise secondary to cardiac issues, orientation alone is within normal limits and is not concerning. This finding does not indicate acute pathology.

• Respiratory: Lungs clear to auscultation bilaterally: Clear lung sounds suggest no active pulmonary congestion, infection, or obstruction. Although dyspnea is present, the absence of adventitious lung sounds indicates that the respiratory system is not acutely compromised. Further evaluation focuses on cardiac or systemic causes rather than pulmonary pathology.