Extract:

Question 1 of 5

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 mL/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 IV heparin that the patient is currently receiving is 50,000 units in 250 mL in NSS. Which of the following action(s)/statement(s) are accurate in this scenario? (Select All that Apply.)

A. The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin mB. After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin KC. The nurses will complete an event report due to the medication errorD. Nurse A will document about the event report in the patients electronic medical record.E. The patient has received a dose of heparin over the prescribed amountF. The patient has received 3200 units of heparin from 1700-1900.

Correct Answer: C,E,F

Rationale: A medication error occurred, the patient received an overdose, and the overdose amount is correctly calculated as 3200 units.

Question 2 of 5

The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

A. Prepare for immediate surgery to repair the open fractureB. Assess for pulses in the upper and lower extremitiesC. Place a sterile pressure dressing on the open fractureD. Maintain C-spine immobilization

Correct Answer: D

Rationale: In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.

Question 3 of 5

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

Correct Answer: A

Rationale: Flow rate = (
Total volume Ã— Drop factor) Ã· Time in minutes = (250 Ã— 15) Ã· 120 = 31.25, rounded to 31 gtt/min.

Question 4 of 5

The nurse is caring for a patient with major burns 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.)

A. distributive shockB. cardiogenic shockC. obstructive shockD. hypovolemic shockE. neurogenic shock

Correct Answer: A,D

Rationale: Severe burns cause hypovolemic shock from fluid loss and distributive shock from systemic inflammatory response syndrome (SIRS).

Question 5 of 5

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

A. White Blood Cell decreaseB. Platelets increaseC. Hemoglobin increaseD. PT and INR normalize

Correct Answer: B

Rationale: The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.