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","D","E"]
Explanation
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to enteral feeding and reduces the risk of aspiration. High residuals may indicate delayed gastric emptying, requiring adjustment of the feeding regimen or provider notification.
B. Check placement of the feeding tube by x-ray once daily: X-ray is the gold standard for initial confirmation of tube placement, not for routine daily checks. Ongoing verification is typically done by assessing pH of gastric aspirate and observing for signs of misplacement, making daily x-rays unnecessary and impractical.
C. Maintain the head of the client's bed at a 30° angle or higher: Elevating the head of the bed reduces the risk of aspiration during continuous enteral feedings. Proper positioning is a key intervention to promote safety and prevent complications such as pneumonia.
D. Change the feeding container and tubing every 24 hr: Changing the feeding container and tubing every 24 hours helps prevent bacterial contamination and infection. This is a standard infection-control measure in enteral feeding care.
E. Ensure the formula is cold before administration: Formula should be at room temperature before administration. Cold formula can cause gastrointestinal discomfort, cramping, and nausea, so heating it to room temperature improves tolerance and safety.
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