A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?
Increased pulse rate.
Increased blood pressure.
Decreased temperature.
Decreased respiratory rate.
The Correct Answer is A
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
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Related Questions
Correct Answer is D
Explanation
Saw palmetto is a natural herbal supplement that may help reduce the symptoms of benign prostate hypertrophy (BPH) by inhibiting the enzyme 5- alpha-reductase, which converts testosterone to dihydrotestosterone (DHT), a hormone that stimulates prostate growth. Some studies have shown that saw palmetto can improve urinary flow and reduce nocturia in men with BPH.
Choice Ais wrong because black cohosh is a plant that contains phytoestrogens, which are compounds that mimic estrogen in the body.Black cohosh is mainly used for menopausal symptoms in women, such as hot flashes and mood swings.
Choice Bis wrong because garlic has no proven effect on BPH. Garlic may have some benefits for cardiovascular health and immune system, but it does not affect prostate size or function.It has no effect on BPH and may even worsen it by altering the hormonal balance.
Choice C is wrong because feverfew is a herb that has anti-inflammatory and anti-migraine properties.
It may help prevent or treat headaches, arthritis, and allergies, but it has no effect on BPH or urinary symptoms.
Correct Answer is D
Explanation
The correct answer is d
Choice A reason:
Administering filgrastim 12 hours after chemotherapy does not typically require an incident report. Filgrastim is often given at least 24 hours after chemotherapy to avoid the risk of increasing the toxicity of the chemotherapy agents. While the timing is closer than recommended, it does not necessarily constitute an error unless specific instructions for the timing were provided by the prescribing physician.
Choice B reason:
The medication vial sitting at room temperature for 2 hours before administration does not require an incident report. Filgrastim can be left out at room temperature for up to 24 hours before use. This is within the safe handling guidelines for the medication.
Choice C reason:
An absolute neutrophil count (ANC) of 2,500/mm³ is within the normal range, which is typically 1,500-8,000/mm³. Filgrastim is used to increase neutrophil counts in patients with low ANC due to chemotherapy. Since the ANC was not low before administration, this would not necessitate an incident report, although it may prompt a review of the necessity of the medication.
Choice D reason:
Flushing the client's IV line with dextrose 5% in water before and after the medication was administered is not the standard procedure and could potentially lead to medication errors or adverse effects. Filgrastim should be diluted in glucose 5% in water for intravenous infusion, but not used to flush the line. This deviation from the standard protocol is what necessitates an incident report.
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