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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 A

Explanation

A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.

B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.

C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.

D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.

A. sudden onset of chest pain and copious sputum B. foul smelling concentrated urine C. oozing blood from iv sites & previous venipuncture sites D. reddened, inflamed central line catheter site

Correct Answer is C

Explanation

A. Sudden onset of chest pain and copious sputum

These are more consistent with pulmonary edema or a respiratory infection, not DIC.

B. Foul-smelling concentrated urine

This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.

C. Oozing blood from IV sites & previous venipuncture sites

DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.

D. Reddened, inflamed central line catheter site

While redness around a catheter site may indicate infection, it is not a defining feature of DIC.

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Naxlex Comprehensive Predictor Exams

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The marse recognizes that which laboratory test order set will most effectively guide the provider to a diagnosis of DIC?

Correct Answer is A

Explanation

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

Correct Answer is C

Explanation

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