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 ["B","E","F"]
Explanation
Rationale:
A. Encourage the client to drink 3000 mL of fluid daily: The client has heart failure with a prescribed fluid restriction of 1000 mL/day. Encouraging excess fluid intake could worsen fluid overload and pulmonary edema, so this is not appropriate.
B. Use soap and water to provide perineal care: Proper perineal hygiene with soap and water reduces the risk of introducing bacteria into the urinary tract, helping prevent catheter-associated urinary tract infections (CAUTIs).
C. Place the drainage bag on the bed when transporting the client: The drainage bag should always be kept below the level of the bladder to prevent backflow and contamination. Placing it on the bed increases the risk of infection and is contraindicated.
D. Change the indwelling urinary catheter tubing every 3 days: Routine changing of the catheter tubing is not recommended as it can increase the risk of infection. Tubing should only be changed if it is compromised, soiled, or obstructed.
E. Empty the drainage bag when it is half-full: Regularly emptying the drainage bag before it becomes overly full prevents backflow and reduces bacterial proliferation, helping to decrease UTI risk.
F. Review the need for the indwelling urinary catheter daily: Assessing the ongoing need for the catheter allows for timely removal, which is the single most effective intervention to prevent catheter-associated urinary tract infections.
Correct Answer is C
Explanation
Rationale:
A. Severe abdominal pain: Severe abdominal pain is more characteristic of placental abruption, not placenta previa. Placenta previa typically causes painless bleeding rather than acute abdominal pain, so pain is not a primary expected finding.
B. Polyhydramnios: Excess amniotic fluid is unrelated to placenta previa and is associated with conditions like fetal anomalies, maternal diabetes, or multiple gestation. It is not a typical clinical finding in this condition.
C. Spotting: Painless vaginal bleeding, often bright red and intermittent, is the hallmark sign of placenta previa. Spotting or heavier bleeding occurs as the placenta overlies or partially covers the cervical os, especially during the third trimester.
D. Nausea: Nausea is a nonspecific symptom and is not directly associated with placenta previa. It may occur during normal pregnancy but does not indicate the presence of this placental condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.