A nurse is collecting data from a client who is 4 hr postoperative following abdominal surgery. The client's blood pressure is 90/60 mm Hg. Which of the following actions should the nurse take first?

The correct answer is 1.5 mL. Here is the explanation:

To calculate the amount of mL to administer, the nurse should use the following formula:

mL = (units ordered / units available) x mL available

Plugging in the values from the question, we get:

mL = (15,000 / 10,000) x 1

mL = 1.5 x 1

mL = 1.5

Therefore, the nurse should administer 1.5 mL of heparin with each dose.

Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.

Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.

Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.

Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.