The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
Notify the healthcare provider.
Monitor for signs of bleeding.
Complete an adverse occurrence report.
Obtain blood for coagulation studies.
The Correct Answer is A
Choice A Reason: This is the correct answer because the nurse should immediately inform the healthcare provider of the medication error and the client's condition. The healthcare provider may order antidotes, such as protamine sulfate for heparin and vitamin K for warfarin, to reverse the anticoagulant effects and prevent bleeding complications.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason: Obtaining blood for coagulation studies is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should obtain blood
samples for coagulation studies, such as prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT), after notifying the healthcare provider and following their orders. The results of these tests can help determine the extent of anticoagulation and guide further therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Demonstrating how to complete an adverse occurrence or variance report is important, but not the most important objective. This report is a tool for quality improvement and risk management, but it does not prevent litigation by itself. The nurse should also communicate effectively with the client and/or their family, and document the incident and the actions taken.
Choice B Reason: Discussing how to handle complaints from clients and/or their families is the most important objective, as it can help prevent or resolve conflicts, and avoid escalation to legal action. The nurse should listen empathetically, acknowledge the client's feelings and concerns, apologize if appropriate, explain the situation and the plan of care, and involve the supervisor or other resources if needed.
Choice C Reason: Describing how to obtain legal services if needed is relevant, but not the most important objective.
This objective implies that litigation is inevitable or expected, which may create a negative or defensive attitude in the staff nurses. The nurse should focus on preventing litigation by providing safe and quality care and building trust and rapport with the clients and/or their families.
Choice D Reason: Maintaining personal malpractice insurance is advisable, but not the most important objective. This objective may protect the nurse's personal assets in case of a lawsuit, but it does not prevent litigation from occurring. The nurse should follow the standards of practice and the policies and procedures of the organization, and document accurately and thoroughly.
Correct Answer is B
Explanation
Choice A Reason: Beginning initial sterile wound care for surgical clients is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The PN may assist with wound care after the initial dressing change, but the RN is responsible for assessing the wound and initiating the plan of care.
Choice B Reason: Validating prescribed intravenous flow rates is a routine task that does not require clinical judgment and can be delegated to the PN. The PN has the knowledge and skill to check the IV orders, calculate the drip rate, and monitor the infusion.
Choice C Reason: Determining the need for urinary catheterizations is a nursing assessment that requires clinical judgment and cannot be delegated to the PN. The PN may perform urinary catheterizations as ordered by the physician, but the RN is responsible for evaluating the indication, risk, and benefit of the procedure.
Choice D Reason: Receiving a postoperative client and conducting the assessment is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The RN is responsible for receiving reports from the operating room, assessing the client's status, identifying potential complications, and initiating the plan of care.
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