A client with a history of deep vein thrombosis (DVT) is receiving a continuous IV heparin infusion. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. Which action should the nurse take? Reference Range: aPTT [25 to 35 seconds, therapeutic range for heparin 1.5 to 2.5 times baseline, approximately 38 to 88 seconds].

Continue the heparin infusion at the current rate.

Increase the heparin infusion rate by 100 units/hour.

Stop the heparin infusion and notify the provider.

Administer protamine sulfate immediately.

Answer and Explanation

The Correct Answer is C

Choice A reason: Continuing heparin at aPTT 120 seconds is unsafe, as it exceeds the therapeutic range (38–88 seconds), indicating excessive anticoagulation. This risks bleeding, as heparin enhances antithrombin, inhibiting clotting factors. Stopping and notifying the provider prevents hemorrhage, making continuation dangerous for this DVT client.

Choice B reason: Increasing heparin is contraindicated with aPTT 120 seconds, far above therapeutic (38–88 seconds). Excessive anticoagulation from heparin’s antithrombin activation heightens bleeding risk. Stopping the infusion and notifying the provider corrects over-anticoagulation, preventing complications like hematoma, making an increase harmful and inappropriate.

Choice C reason: Stopping heparin and notifying the provider is critical at aPTT 120 seconds, indicating over-anticoagulation. Heparin’s inhibition of clotting factors increases bleeding risk in DVT treatment. Halting infusion prevents hemorrhage, and provider notification ensures dose adjustment or reversal, addressing the pathophysiological risk effectively and promptly.

Choice D reason: Administering protamine sulfate reverses heparin but requires provider order, as aPTT 120 seconds indicates high bleeding risk. Stopping infusion first prevents further anticoagulation, and notifying the provider ensures guided reversal, avoiding premature protamine use, which risks anaphylaxis or thrombosis, making this less immediate.

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Correct Answer is D

Explanation

Choice A reason: Orientation to person and place only suggests confusion, common in right hemisphere stroke affecting non-dominant cognition. This is not immediately life-threatening. Pupillary dilation indicates increased intracranial pressure (ICP) or herniation, a critical emergency requiring urgent intervention to prevent brain stem damage or death.

Choice B reason: Unequal hand grip strengths indicate hemiparesis, typical in right hemisphere stroke affecting left-sided motor function. This is expected and not acutely life-threatening. Pupillary dilation signals rising ICP or herniation, necessitating immediate intervention to prevent catastrophic neurological decline, making it the priority finding.

Choice C reason: Left-sided facial drooping and dysphagia are common in right hemisphere stroke, reflecting contralateral cranial nerve deficits. These are serious but not immediately life-threatening. Pupillary dilation indicates potential herniation from ICP, requiring urgent intervention like mannitol to prevent brain stem compression and fatal outcomes.

Choice D reason: Ipsilateral pupillary dilation in right hemisphere stroke signals increased ICP or herniation, compressing the oculomotor nerve (CN III), impairing pupillary constriction. This life-threatening emergency indicates impending brain stem compromise, requiring immediate intervention with ICP-lowering measures or surgery to prevent irreversible damage or death.

A. Palpitations and shortness of breath. B. Lethargy and lack of appetite. C. Muscle cramping and dry, flushed. D. Bradycardia and constipation.

Correct Answer is A

Explanation

Choice A reason: Excessive levothyroxine causes hyperthyroidism, increasing T3/T4, stimulating beta-adrenergic receptors, leading to palpitations (tachycardia) and shortness of breath from heightened cardiac workload and oxygen demand. These indicate overdose, risking atrial fibrillation, requiring immediate dose adjustment to prevent cardiovascular complications in this thyroid-treated client.

Choice B reason: Lethargy and lack of appetite suggest hypothyroidism, indicating low thyroid hormone levels from insufficient levothyroxine. These are opposite to overdose symptoms like palpitations, driven by excessive metabolism. High doses cause hyperthyroid effects, making this incorrect for identifying excessive dosing in goiter treatment.

Choice C reason: Muscle cramps and dry, flushed skin are not typical of levothyroxine overdose. Hyperthyroidism causes warm, moist skin from increased metabolism, not dryness. Cramps relate to electrolytes. Palpitations and shortness of breath are hallmark overdose signs, reflecting thyroid-driven cardiovascular overstimulation, making this less accurate.

Choice D reason: Bradycardia and constipation indicate hypothyroidism from low thyroid hormones, reducing heart rate and metabolism. This suggests inadequate levothyroxine, not overdose. Excessive doses cause hyperthyroidism, with palpitations and dyspnea from metabolic hyperactivity, making these symptoms incorrect for high-dose levothyroxine effects.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Correct Answer is D

Explanation

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is A

Explanation

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?

A client who has been hospitalized with an exacerbation of heart failure experiences severe dyspnea with activity and remains on bedrest. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?

A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. What action(s) should the nurse take? (Select all that apply)