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?
Complete an incident report.
Check the client for indications of bleeding.
Monitor the client's aPTT levels
Notify the risk manager.
The Correct Answer is B
Choice A reason:
Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.
Choice B reason:
Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.
After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.
Choice C reason:
Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.
Choice D reason:
Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct first action for the charge nurse to take in response to an increase in facility-acquired catheter infections is toidentify possible precipitating factors related to the infections. This is because understanding the root cause of the problem is crucial before implementing any changes or interventions. By identifying the factors contributing to the increase in infections, the nurse can then develop targeted strategies to address these specific issues.
Now, let’s discuss why the other options are not the first actions to take:
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Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.
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Meet with providers to discuss measures to decrease the infections: This could be a subsequent step after identifying the precipitating factors. Meeting with providers without concrete data or understanding of the problem may lead to ineffective solutions.
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Revise the current policy for catheter care: Policy revision should be based on evidence and identified needs. It would be premature to revise policies without first understanding what factors are contributing to the increase in infections.
In summary, the first step in addressing a problem is always to understand its causes. Only then can effective solutions be developed and implemented.
Correct Answer is D
Explanation
The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A
bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
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