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Author Question: The nurse notes that a patient with cardiac disease has IV heparin infusing and that it is behind by ... (Read 26 times)

mckennatimberlake

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The nurse notes that a patient with cardiac disease has IV heparin infusing and that it is behind by 2 hours. What is the best nursing action?
 
  a. Increase the IV rate and recheck in 1 hour.
  b. Change the infusion rate to TKO.
  c. Discontinue the solution using aseptic technique.
  d. Contact the health care provider for consultation.

Question 2

The nurse determines that an elderly patient's IV of D50.2 NS with 20 mEq KCl at 75 mL/hr is running 3 hours behind. After determining the IV site is patent, what action will the nurse take?
 
  a. Call the health care provider to obtain an order to decrease the IV rate.
  b. Administer a bolus to make up the deficit.
  c. Recalculate the flow rate and slowly make up the fluids.
  d. Maintain the ordered rate.



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leahm14

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Answer to Question 1

ANS: D
The patient has a history of cardiac problems and is receiving a critical care medication, IV heparin. In this case, contacting the patient's health care provider would be appropriate to avoid harm. Increasing the infusion rate might place the patient into fluid overload and might infuse too much heparin in a short time. Reducing the infusion rate to TKO or discontinuing the solution would put the schedule even further behind.

Answer to Question 2

ANS: D
The safest action is to maintain the ordered rate. The health care provider should be consulted if the patient has not received critical IV replacement therapy. Increasing an IV rate without a health care provider's order can be detrimental for patients who have cardiac, renal, or circulatory impairment. Normal aging process results in decreased cardiac, renal, and circulatory function. The rate ordered is the one the provider intended for the administration of fluids; changing it to fit the prevailing situation is not appropriate. The bolus technique should only be used for the administration of medications or fluid challenges in patients who need a volume of IV fluid quickly. The flow rate must be consistent with the provider's order.





 

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