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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","B"]

Explanation

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

A. includes the head-to-toe anterior and posterior assessment. B. priorities are continuing and ongoing but treatment will be deferred if the clients unstables C. is focused on airway maintenance and ventilation effectiveness. D. focuses on the ABCDs of the client to identify life threatening problems

Correct Answer is D

Explanation

A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

Correct Answer is D

Explanation

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is

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

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

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