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A patient is ordered a heparin infusion at 1200 units/hour. Historically. IV heparin is premixed as 25.000 units of heparin in 250 mL NSS at the institution. Nurse A starts the infusion at 12 m/hr at 1700. The nurse asks their colleague to cosign the infusion for a prescribed rate change at 1900. Nurse B reminds Nurse A that there has been a recent pharmacy policy change. The V heparin that the patient is currently receiving is 50.000 units in 250 mL in NSS. Which of the following action(s)/statements) are accurate in this scenario?
(Select All that Apply.)

The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin m

After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin K

The nurses will complete an event report due to the medication error

Nurse A will document about the event report in the patients electronic medical record.

The patient has received a dose of heparin over the prescribed amount

The patient has received 3200 units of heparin from 1700-1900.

Answer and Explanation

Correct Answer : C,E,F

A. The correct rate is 6 mL/hr

The correct calculation should be verified.

B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K

Protamine sulfate, not vitamin K, is the antidote for heparin.

C. The nurses will complete an event report due to the medication error

A medication error must be reported.

D. Nurse A will document about the event report in the patient’s EMR

Incident reports are internal documents and should not be documented in the EMR.

E. The patient has received a dose of heparin over the prescribed amount

Due to the increased concentration, the patient received more heparin than intended.

F. The patient has received 3200 units of heparin from 1700-1900.

This calculation confirms overdosing.

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Correct Answer is D

Explanation

A. Avoid using an electric razor
This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.

B. Meats should be served hot
Hot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.

C. Teeth should be brushed prior to each meal
This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.

D. Chew food on the unaffected side
Clients with trigeminal neuralgia may experience severe pain on one side of the face, especially when chewing. To reduce pain, it is recommended to chew food on the unaffected side to avoid triggering pain.

A. Administer each unit of blood over 34 hour B. Anticipate an order for acetaminophen C. Anticipate an order for furosemide administration D. Assess for signs and symptoms of fluid overload E. Anticipate administration of FFP for the next transfusion

Correct Answer is ["A","C","D"]

Explanation

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

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Naxlex Comprehensive Predictor Exams

Which of the following measures would the nurse emphasize to assist the client diagnosed with trigeminal neuralgia in managing their pain?

Correct Answer is D

Explanation

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

Correct Answer is ["A","C","D"]

Explanation

Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

The nurse is caring for a client, with no other pertinent medical history, who was burned over 709% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

How should the nurse evaluate the client's motor ability and function?

The nurse is caring for a client with trigeminal neuralgia. Which medical prescription would the nurse anticipate?

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?