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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

No explanation

A. “I can adjust the time and schedule for when it’s convenient for you.”. B. “I can start the medication 30 minutes earlier.”. C. “I have up to 2 hours after the usual schedule time to give you this medication.”. D. “I can infuse the medication at a faster rate.”. E. None F. None

Correct Answer is C

Explanation

The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment.

Correct Answer is D

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?

A nurse is providing teaching to a client who is to begin external radiation therapy for cancer. Which of the following information should the nurse include?

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?

A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?