A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

Remove all objects that contain latex from the client’s room.

Verify the client’s medication prescriptions do not include cephalosporin.

Notify dietary services to adjust the client’s diet.

Have the client purchase a medication alert bracelet to wear in the hospital.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Removing all objects that contain latex from the client’s room is important for clients with a latex allergy, not a penicillin allergy. Latex allergies can cause severe reactions, including anaphylaxis, but this action is not relevant to a penicillin allergy.

Choice B reason:

Verifying that the client’s medication prescriptions do not include cephalosporin is crucial because cephalosporins can have cross-reactivity with penicillin. Clients with a penicillin allergy may also react to cephalosporins, so it is essential to avoid prescribing these antibiotics.

Choice C reason:

Notifying dietary services to adjust the client’s diet is not directly related to managing a penicillin allergy. Dietary adjustments are more relevant for clients with food allergies or specific dietary restrictions.

Choice D reason:

Having the client purchase a medication alert bracelet to wear in the hospital is a good practice for general safety, but it is not an immediate action the nurse should take during the admission process. The primary focus should be on ensuring that the client’s medications do not include penicillin or related antibiotics.

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Correct Answer is D

Explanation

Choice A reason:

Administer 50,000 units of heparin by IV bolus every 12 hours: This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.

Choice B reason:

Have vitamin K available on the nursing unit: Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.

Choice C reason:

Use tubing specific for heparin sodium when administering the infusion: While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.

Choice D reason:

Check the activated partial thromboplastin time (aPTT) every 6 hours: This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.

Correct Answer is ["5"]

Explanation

Step 1: Determine the total volume to be infused. = 1 liter (L)

Step 2: Convert the total volume from liters to milliliters (mL). Calculation: 1 L × 1000 mL/L = 1000 mL

Step 3: Determine the infusion rate. = 200 mL/hr

Step 4: Calculate the infusion time in hours. Calculation: 1000 mL ÷ 200 mL/hr = 5 hours

Step 5: Round the answer to the nearest whole number if necessary. = 5 hours (no rounding needed)

The nurse should expect the IV pump to infuse over 5 hours.

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A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["5"]

Explanation

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