Question

When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A) Administer heparin via continuous IV infusion.
B) Administer a diuretic to reduce fluid overload.
C) Provide supplemental oxygen to support respiratory function.
D) Initiate nasogastric tube insertion for nutritional support.

Answer 1

In a case prioritizing circulation where a clot may be present, administering heparin via continuous IV infusion is the correct intervention as it prevents further clot formation.

Step-by-step explanation:

When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation. In the context of a suspected or evident clot (like in cases of obstructive shock or pulmonary embolism), administering heparin to prevent further clot formation is a priority intervention. Hence, the correct answer is A) Administer heparin via continuous IV infusion. This is because heparin is an anticoagulant, and administering it can help to stabilize circulation by preventing new clots from forming and stopping existing clots from getting larger. Providing supplemental oxygen and inserting a nasogastric tube are supportive measures, but they are not the primary interventions in case of circulation compromised by a clot.