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The client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Correct Answer: 11
Rationale: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
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The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
The nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. Prioritize the order in which the nurse should address each client’s laboratory result.
- A. Troponin T 42 ng/mL (0.0-0.4 ng/mL)
- B. WBC 11,000/mm3
- C. Hgb 7.2 g/dL
- D. SCr 2.2 mg/dL
- E. K 2.2 mEq/L
- F. Total cholesterol 430 mg/dL
Correct Answer: A;E;C;D;F;B
Rationale: The nurse should prioritize: A) Elevated troponin indicates MI, requiring immediate action; E) Low potassium can cause dysrhythmias; C) Low hemoglobin contributes to ischemia; D) Elevated creatinine suggests renal impairment; F) High cholesterol is a long-term risk; B) Normal WBC is least urgent.
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.
The client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?
- A. Call the HCP immediately; administer diphenhydramine.
- B. Stop the infusion; apply a warm, moist compress to the affected area.
- C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
- D. Discontinue the potassium chloride; document the client’s allergic reaction.
Correct Answer: B
Rationale: The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm, moist compress and restart the IV at another location, giving the infusion at a slower rate. Other options misinterpret the situation as an allergy or fail to address the phlebitis.