A nurse is managing the parenteral therapies for several clients on a medical-surgical unit. Which of the following nursing actions indicate safe and appropriate practice? (Select all that apply.)
- Verifying a client's baseline activated partial thromboplastin time (aPTT) and platelet count before initiating a continuous intravenous (IV) heparin infusion.Cevap
- BProgramming an IV infusion pump to 50 mL/hr to deliver a prescribed dose of 5 units/hr of regular insulin, using a 100 units/100 mL concentration.
- CAdministering an IV push dose of phenytoin directly into a continuous infusion line of dextrose 5% in water (D5W).
- Hanging an infusion of 10% dextrose in water (D10W) at the same rate when a client's next scheduled bag of total parenteral nutrition (TPN) is temporarily delayed.Cevap
- EAssessing a client who reports mild pruritus around a peripheral IV dressing before attending to a client whose continuous IV nitroglycerin infusion pump is alarming.
Cevap
The correct actions are verifying the aPTT and platelet count prior to initiating heparin, and hanging 10% dextrose in water (D10W) when a TPN bag is delayed.
Verifying baseline coagulation values before starting heparin is essential to monitor for therapeutic effect and adverse reactions like heparin-induced thrombocytopenia. Additionally, hanging D10W when TPN is delayed is a standard safety protocol to prevent rebound hypoglycemia caused by the sudden withdrawal of a high-glucose continuous infusion.
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Anahtar Kavram
Safe parenteral therapy requires accurate dosage calculations, verification of IV fluid compatibility, proactive complication management (such as preventing hypoglycemia with TPN), and appropriate prioritization of critical medication infusions.
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