A client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client’s PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Consult with the health care provider about discontinuing heparin

Increase the heparin infusion by 100 units per hour

Begin treatment with the prescribed warfarin (Coumadin)

Continue with the present infusion rate of heparin

Answer and Explanation

The Correct Answer is A

Reasoning:

Choice A reason: Consulting the provider about discontinuing heparin is critical, as the client’s laboratory findings show a significant platelet drop (170,000 to 70,000/mm3), suggesting heparin-induced thrombocytopenia (HIT). HIT involves immune-mediated platelet destruction, increasing thrombosis risk. Stopping heparin prevents further platelet decline and thrombotic complications, making this the most urgent action.

Choice B reason: Increasing the heparin infusion is dangerous, as the platelet drop suggests HIT, where heparin triggers platelet activation and clotting. Further heparin administration could worsen thrombocytopenia and increase thrombosis risk, leading to severe complications like pulmonary embolism or stroke, making this action contraindicated.

Choice C reason: Beginning warfarin is inappropriate without addressing the platelet drop, likely due to HIT. Warfarin does not reverse thrombocytopenia and may increase bleeding risk in a thrombocytopenic patient. Heparin must be stopped first, and alternative anticoagulants considered, making warfarin initiation premature and risky.

Choice D reason: Continuing the current heparin rate is unsafe, as the significant platelet decline indicates possible HIT. Maintaining heparin could exacerbate platelet destruction and thrombosis risk, leading to life-threatening complications. Consulting the provider to discontinue heparin and investigate HIT is the priority to ensure patient safety.

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Correct Answer is C

Explanation

Reasoning:

Choice A reason: Thiazide diuretics reduce urine output in nephrogenic diabetes insipidus by increasing sodium excretion, which enhances water reabsorption indirectly. However, they are not the primary treatment for central diabetes insipidus, where ADH deficiency is the issue. Desmopressin, an ADH analog, directly addresses the hormonal deficiency, making thiazides less effective.

Choice B reason: Diabinese (chlorpropamide) is a sulfonylurea used for type 2 diabetes mellitus, not diabetes insipidus. It lowers blood glucose by stimulating insulin release, which is irrelevant to the water balance issue in diabetes insipidus caused by ADH deficiency. It does not address the underlying hormonal imbalance.

Choice C reason: Desmopressin (DDAVP) is a synthetic ADH analog used to treat central diabetes insipidus. It mimics ADH, promoting water reabsorption in the kidneys’ collecting ducts, reducing polyuria and thirst. This directly corrects the fluid imbalance caused by ADH deficiency, making it the primary and most effective treatment.

Choice D reason: Ibuprofen, a nonsteroidal anti-inflammatory drug, is used for pain and inflammation, not for fluid balance in diabetes insipidus. It has no effect on ADH or renal water reabsorption, making it irrelevant for treating the excessive urine output and dehydration associated with this condition.

A. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks B. The client should mobilize as soon as physically able C. The client should remain on bed rest until the client expresses a desire to mobilize D. Lack of mobility will greatly increase the client’s risk of stroke recurrence

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Limiting bed rest to 4 weeks to prevent contractures and atrophy is not the primary principle. While prolonged immobility causes these issues, early mobilization post-stroke improves recovery and prevents complications like thromboembolism, making immediate mobilization the key focus rather than a time limit.

Choice B reason: Mobilizing as soon as physically able is critical post-ischemic stroke to enhance recovery. Early mobilization improves circulation, prevents thromboembolism, maintains muscle strength, and promotes neuroplasticity, reducing disability. This principle counters the family’s insistence on bed rest, which increases complication risks and hinders recovery.

Choice C reason: Waiting for the client to express a desire to mobilize delays recovery. Stroke patients may lack initiative due to neurological deficits or depression. Early mobilization, guided by physical ability, prevents complications like deep vein thrombosis and supports rehabilitation, making patient desire a poor criterion.

Choice D reason: Lack of mobility does not directly increase stroke recurrence risk, which is more tied to vascular risk factors like hypertension or diabetes. However, immobility increases complications like thromboembolism, which could indirectly contribute to stroke. Early mobilization is the priority to enhance overall recovery.

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A client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client’s PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

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Naxlex Comprehensive Predictor Exams

Which of the following medications is used in the treatment of diabetes insipidus to control fluid balance?

Correct Answer is C

Explanation

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client’s family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse’s response to the family?

Correct Answer is B

Explanation

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