NURS 2873 - Medication Management, Error Prevention, & Patient Education LAB

Susan Slipnslide weighs 152 lb. What is her weight in kilograms?

152 lb ÷ 2.2 = 69.1 kg.

Susan Slipnslide is ordered an initial heparin bolus of 80 units/kg IV. How many units should she receive?

69.1 kg × 80 units/kg = 5,528 units IV, approximately 5,530 units.

Susan is ordered a heparin infusion at 18 units/kg/hr. How many units/hr should she receive initially?

69.1 kg × 18 units/kg/hr = approximately 1,244 units/hr.

At 1500 Susan's aPTT is 105 sec. According to her heparin protocol, what should the nurse do?

Reduce the heparin infusion by 2 units/kg/hr because an aPTT of 105–125 sec requires a 2 units/kg/hr reduction.

Susan's heparin infusion is 18 units/kg/hr and her aPTT is 105 sec. What is her new dose in units/kg/hr?

Reduce by 2 units/kg/hr: 18 − 2 = 16 units/kg/hr.

After Susan's heparin is reduced to 16 units/kg/hr, what is her new infusion dose in units/hr?

69.1 kg × 16 units/kg/hr = approximately 1,106 units/hr.

After adjusting Susan's heparin infusion, when should another aPTT be obtained?

Repeat the aPTT in 6 hours after the dosage adjustment.

What laboratory tests should continue to be monitored for Susan while receiving heparin and warfarin?

aPTT every 6 hours as ordered, CBC daily, and PT/INR daily.

At 1500 Susan's PT/INR is 12.7/1.1. Should the nurse give or hold her ordered warfarin 5 mg?

Give the warfarin 5 mg PO because INR 1.1 is subtherapeutic.

Why can Susan receive heparin and warfarin at the same time?

They are intentionally overlapped because warfarin takes several days to become therapeutic while heparin provides immediate anticoagulation.

Does Susan's elevated aPTT of 105 sec mean her warfarin should be held?

No. aPTT primarily monitors unfractionated heparin; PT/INR monitors warfarin.

What is the typical therapeutic INR range for warfarin treatment of DVT/PE?

Usually INR 2–3.

What does subtherapeutic mean?

The medication effect or laboratory value is below the desired therapeutic range, meaning treatment may be inadequate.

Give an example of a subtherapeutic heparin level using Susan's protocol.

An aPTT below 68 seconds is subtherapeutic according to this protocol.

Give an example of a subtherapeutic warfarin level for DVT/PE treatment.

INR below 2 is generally subtherapeutic for DVT/PE treatment.

What does supratherapeutic mean?

The medication effect or laboratory value is above the desired therapeutic range, increasing the risk of adverse effects such as bleeding.

Give an example of a supratherapeutic heparin level using Susan's protocol.

An aPTT above 104 seconds is above the therapeutic range on this protocol.

Give an example of a supratherapeutic warfarin level for typical DVT/PE treatment.

INR above 3 is generally supratherapeutic for a target range of 2–3.

Why does Susan need a CBC daily while receiving anticoagulation?

Monitor Hgb/Hct for bleeding and platelet count for heparin-induced thrombocytopenia (HIT).

Why is Susan's aPTT checked every 6 hours?

To measure the effect of unfractionated heparin and determine whether the infusion needs adjustment.

Why is Susan's PT/INR checked daily?

To monitor the anticoagulant effect of warfarin and determine when it reaches the therapeutic range.

What is the antidote for heparin?

Protamine sulfate.

What is the antidote for warfarin?

Vitamin K, also called phytonadione.

What findings in Susan support DVT with pulmonary embolism?

Sudden SOB and chest pain, right calf redness/swelling, positive RLE Doppler for DVT, positive D-dimer, and CT showing multiple small pulmonary emboli.

Why should Susan be closely monitored for bleeding?

She is postoperative, receiving anticoagulants, had moderate blood loss/transfusion, and her Hgb/Hct are already low at 9.1/27.

John Sweet weighs 193 lb. What is his weight in kilograms?

193 lb ÷ 2.2 = approximately 87.7 kg.

John Sweet is ordered regular insulin 0.1 units/kg IV bolus. How many units should he receive?

87.7 kg × 0.1 units/kg = 8.77 units, approximately 9 units regular insulin IV.

How should John's regular insulin bolus be administered?

As an IV bolus of regular insulin using the appropriate insulin preparation/equipment and facility IV-insulin policy.

John is ordered regular insulin at 0.1 units/kg/hr. How many units/hr will he receive?

87.7 kg × 0.1 units/kg/hr = approximately 8.77 units/hr.

If John's regular insulin infusion concentration is 1 unit/mL, what pump rate should be programmed?

8.77 units/hr ÷ 1 unit/mL = approximately 8.8 mL/hr.

What major medication error is present in John's orders?

Glargine (Lantus) 10 units is ordered intravenously even though insulin glargine is administered subcutaneously, not IV.

What should the nurse do about John's order for Lantus 10 units IV daily?

Hold the medication and contact the provider to clarify/correct the route to subcutaneous administration.

Which insulin is appropriate for John's continuous IV insulin infusion?

Regular insulin.

Why must the nurse verify the correct syringe/equipment when administering insulin?

Insulin is a high-alert medication and incorrect syringes or concentrations can cause serious dosing errors.

What findings indicate that John is experiencing diabetic ketoacidosis (DKA)?

Glucose 531, positive urine ketones/glucose, anion gap 22, CO2 20, fruity breath, abdominal pain, nausea, dehydration, tachycardia, tachypnea, lethargy, and confusion.

Why is the 2-L normal saline bolus important for John with DKA?

DKA causes severe dehydration and volume depletion, so IV isotonic fluid restores circulating volume and perfusion.

Why is potassium important to monitor during John's DKA treatment even though his initial K+ is 4.0?

Insulin drives potassium into cells and serum potassium may rapidly fall during treatment.

What blood glucose monitoring is ordered while John receives an insulin infusion?

Capillary blood glucose every hour with insulin titration as directed.

What discharge teaching should John receive about blood glucose monitoring?

Check blood glucose regularly, especially with illness, schedule changes, missed meals, or symptoms of hyper/hypoglycemia.

What discharge teaching should John receive about his insulin?

Take basal and mealtime insulin consistently and do not forget insulin because of school, studying, or an irregular schedule.

When should John check ketones after discharge?

When ill or when blood glucose is very high, according to his diabetes sick-day plan.

What DKA warning signs should John know?

Nausea, vomiting, abdominal pain, fruity breath, excessive thirst/urination, dehydration, rapid breathing, lethargy, and confusion.

What lifestyle planning could help prevent another episode of DKA for John?

Plan meals, insulin administration, glucose checks, hydration, and diabetes supplies even during exams or other busy periods.

Bernard Goldon has a blood glucose of 290 mg/dL. How much lispro should he receive according to his sliding scale?

261–300 mg/dL = 10 units lispro SQ.

Which medications in Bernard's chart can be administered based on the available data?

Aspirin 81 mg, amlodipine 2.5 mg, atorvastatin 20 mg, and lispro 10 units SQ if the glucose of 290 is his AC/premeal reading.

Why should Bernard receive aspirin 81 mg after his MI and stent?

Aspirin provides antiplatelet therapy and helps prevent thrombus formation after MI/stent placement.

Why should Bernard receive atorvastatin after his MI?

Statin therapy lowers cardiovascular risk and is used for secondary prevention after MI.

Why can Bernard's amlodipine 2.5 mg generally be administered?

His blood pressure is elevated at 150/90 and there is no listed contraindication to the ordered dose.

Which medication should be held because Bernard's heart rate is 50 bpm?

Metoprolol XL 100 mg should be held and the provider notified because it can further decrease his heart rate.

Why is metoprolol concerning for Bernard?

He already has sinus bradycardia at 50 bpm, and beta blockers can worsen bradycardia.

Why should Bernard's furosemide 40 mg IV be held or clarified?

His potassium is already low at 3.0 mEq/L, and furosemide can lower potassium further.

Why does Bernard still have a clinical need for furosemide despite the potassium concern?

He has bibasilar crackles, lower-extremity edema, low O2 saturation, and chest x-ray evidence of mild pulmonary edema.

What should the nurse anticipate for Bernard's potassium of 3.0 mEq/L?

Notify the provider and anticipate potassium replacement with continued cardiac monitoring.

Why are Bernard's occasional PVCs especially concerning with a potassium of 3.0?

Hypokalemia increases the risk of cardiac dysrhythmias.

What information should the nurse communicate to Bernard's physician?

HR 50 with metoprolol ordered, K+ 3.0 with IV furosemide ordered, PVCs, and pulmonary edema; request clarification and potassium replacement.

What should Bernard be taught about medications after an MI/stent?

Take medications exactly as prescribed, especially antiplatelet and cardiovascular medications, and do not stop them without provider instructions.

What diet education is appropriate for Bernard?

Follow a heart-healthy and diabetic diet with appropriate sodium, fat, carbohydrate, and calorie control.

What symptoms should Bernard report after discharge?

Chest pain, worsening SOB, increasing edema, rapid weight gain, palpitations, dizziness, or other concerning cardiac symptoms.

Jacob Sills has acetaminophen 1 g PO every 4 hours PRN ordered at discharge. What is the maximum amount he could take in 24 hours?

1 g every 4 hours = 6 doses/day = 6 grams/day.

Why is Jacob's acetaminophen 1 g every 4 hours PRN prescription unsafe?

It could total 6 g/day, exceeding the usual adult maximum of 4 g/day.

Why is excessive acetaminophen especially concerning for Jacob?

His liver enzymes are already elevated: AST 202 and ALT 191.

What should the nurse do before carrying out Jacob's discharge acetaminophen prescription?

Contact the provider and clarify/reduce the acetaminophen dose or frequency before discharge.

What medication/MAR discrepancy is present in Jacob's chart?

The MAR lists 0.9% sodium chloride IV at 100 mL/hr, but no corresponding IV-fluid provider order was supplied.

What should the nurse do if a medication or IV fluid appears on the MAR without a valid provider order?

Do not administer it; clarify the order before proceeding.

What findings support infectious mononucleosis in Jacob?

Positive Monospot, lymphocytosis, fever, malaise, pharyngitis, lymphadenopathy, splenomegaly, and elevated liver enzymes.

What is the most important activity restriction for Jacob with splenomegaly?

Avoid contact sports, heavy lifting, and activities that could cause abdominal trauma.

Why must Jacob avoid contact sports and abdominal trauma?

Splenomegaly increases his risk of splenic rupture and potentially life-threatening internal bleeding.

Why should Jacob avoid alcohol while recovering?

His AST and ALT are elevated, indicating liver involvement, and alcohol can cause additional hepatic stress.

What should Jacob know about acetaminophen use at home?

Avoid excessive acetaminophen and follow the corrected prescribed dose because high doses can cause liver toxicity.

Which symptoms could indicate splenic rupture in Jacob?

Sudden severe LUQ abdominal pain, left shoulder pain, dizziness, weakness, fainting, or other signs of internal bleeding.

What general self-care teaching should Jacob receive for mono?

Rest, maintain hydration, manage symptoms safely, and avoid activities that risk abdominal injury.

Margot Bills has a documented Ancef allergy but cefazolin is ordered. Why is this an error?

Ancef is the brand name for cefazolin, so the ordered medication is the same drug to which she has a documented allergy.

What should the nurse do with Margot's cefazolin 1 g IV order?

Do not administer it; notify the provider and request clarification or an alternative antibiotic.

Margot's HCG is positive and her home medications include lisinopril. What is the concern?

Lisinopril is an ACE inhibitor and is contraindicated in pregnancy because it can cause fetal toxicity.

What should the nurse do with Margot's lisinopril after discovering the positive pregnancy test?

Hold lisinopril and notify the provider for an alternative blood pressure treatment.

Why should Margot's ibuprofen 800 mg PRN order be clarified?

Pregnancy has been newly identified, gestational age is uncertain, and NSAID use can cause fetal complications, especially later in pregnancy.

What three major medication concerns should be communicated to Margot's physician?

Ancef/cefazolin allergy conflict, positive pregnancy with lisinopril therapy, and the need to reconsider/clarify ibuprofen use.

Why should unnecessary BP cuffs, venipunctures, or procedures be avoided in Margot's affected left arm when possible?

The arm/hand is infected, swollen, and inflamed from cellulitis, so avoid additional trauma when another site is available.

What should Margot be taught about her cefazolin allergy?

Tell all healthcare providers that she is allergic to Ancef/cefazolin and recognize that Ancef and cefazolin are the same medication.

What medication teaching is important now that Margot is pregnant?

Tell healthcare providers about the pregnancy before taking new medications and do not continue contraindicated drugs such as lisinopril without provider direction.

What signs of worsening cellulitis should Margot report?

Increasing redness, swelling, pain, drainage, streaking, fever, or other signs that the infection is spreading.

James S. Putum has O2 saturation 82%, BP 80/42, MAP 55, HR 131, and lactate 7.2. What condition do these findings indicate?

Severe sepsis with septic shock and impaired tissue perfusion.

What is the first priority intervention for James?

Apply high-concentration oxygen by non-rebreather and prepare for intubation/mechanical ventilation because O2 saturation is 82%.

Why is oxygen the first priority for James?

Airway and breathing take priority, and his severe hypoxemia threatens immediate organ oxygenation.

What fluid resuscitation is ordered for James?

0.9% sodium chloride 30 mL/kg IV bolus.

James weighs 252 lb. What is his weight in kilograms?

252 lb ÷ 2.2 = approximately 114.5 kg.

How much 0.9% sodium chloride should James receive for a 30 mL/kg bolus?

114.5 kg × 30 mL/kg = approximately 3,435 mL, or about 3.4 L.

What is the purpose of the 30 mL/kg normal saline bolus in septic shock?

Restore intravascular volume, improve tissue perfusion, and raise blood pressure/MAP.

What blood cultures should be obtained for James?

Two sets of blood cultures should be drawn before antibiotics when possible without significantly delaying antimicrobial therapy.

Why are blood cultures obtained before antibiotics in sepsis?

They help identify the causative organism and guide targeted antimicrobial therapy.

Should antibiotics be significantly delayed while waiting for cultures in septic shock?

No. Obtain cultures promptly when possible, but do not significantly delay antibiotics.

What broad-spectrum antibiotic in James's orders can be administered while considering allergies?

Vancomycin can be administered as ordered while the Zosyn allergy conflict is clarified, with renal monitoring.

Why is James's piperacillin/tazobactam (Zosyn) order a concern?

He has a penicillin allergy, and piperacillin is a penicillin-class antibiotic.

What should the nurse do with James's Zosyn order?

Hold it and clarify the allergy/order with the provider before administration.

Why should James's renal function be closely monitored with vancomycin?

His creatinine is already elevated at 2.0 mg/dL, and vancomycin can contribute to nephrotoxicity.

What is James's starting norepinephrine dose according to the order?

8 mcg/min IV, titrated within the ordered range to maintain MAP greater than 65 mm Hg.

When is norepinephrine used in septic shock?

When hypotension persists despite or during appropriate fluid resuscitation to maintain adequate MAP and organ perfusion.

Is norepinephrine a vasoconstrictor or vasodilator?

Vasoconstrictor.

How does norepinephrine raise blood pressure?

It primarily stimulates alpha-1 receptors, causing vasoconstriction and increasing systemic vascular resistance and MAP.

What MAP goal is ordered for James?

MAP greater than 65 mm Hg.