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
Explanation
Rationale:
A. Hypotension: While hypotension can indicate shock or fluid imbalance, it may develop secondary to other complications. It is concerning but not necessarily the earliest indicator of an acute pulmonary embolism.
B. Dyspnea: Sudden or worsening shortness of breath is the most immediate sign of a possible pulmonary embolism, which is life-threatening. Prompt recognition and reporting are critical to initiate interventions such as oxygen therapy, anticoagulation, or advanced imaging.
C. Dry cough: A dry cough may accompany a pulmonary embolism but is nonspecific and less urgent. It does not indicate immediate compromise compared with respiratory distress or hypoxia.
D. Tachycardia: Elevated heart rate can be an early sign of stress or hypoxia but is less specific than dyspnea. Tachycardia warrants monitoring, but shortness of breath takes priority for immediate action.
Correct Answer is C
Explanation
Rationale:
A. Inform the transferring agency of the client's condition: While notifying the transferring facility may be part of documentation or reporting, it does not directly address suspicions of abuse. The priority is to gather accurate information from the client in a safe and confidential manner before reporting.
B. Notify risk management: Risk management may be involved in internal investigation processes, but contacting them is not the first step when abuse is suspected. Immediate priority is assessing the client’s safety and obtaining information about the injuries.
C. Privately interview the client about the injuries: Conducting a private, nonjudgmental interview allows the nurse to gather direct information about the cause of the injuries without influence or intimidation from others. This is a critical first step in identifying potential elder abuse, ensuring the client’s safety, and providing evidence for appropriate reporting.
D. Contact the family regarding the client's condition: Contacting family members before assessing the client can compromise the investigation, particularly if family members are potential perpetrators. Privacy and safety of the client must be prioritized before involving others.
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