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.

Answer and Explanation

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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Correct Answer is C

Explanation

Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.

Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.

Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.

Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.

Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.

Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.

A. You should anticipate taking medication to treat your disease for at least the next 3 years. B. You will need to undergo tuberculin skin tests every 6 months while taking medication for your disease. C. You should report monthly to have your blood drawn to monitor kidney function while taking medication. D. You will need to take two or more medications to treat your disease.

Correct Answer is D

Explanation

This is because TB is caused by a bacterium that can develop resistance to single-drug therapy, so a combination of drugs is used to prevent or treat drug-resistant strains. Some of the common drugs used for TB are isoniazid, rifampin, ethambutol, and pyrazinamide.

Choice A is wrong because the duration of treatment for active TB is usually 6 to 9 months, not 3 years.

Choice B is wrong because tuberculin skin tests are not reliable indicators of disease activity or response to treatment, as they can remain positive for years after successful therapy.

Choice C is wrong because blood tests to monitor kidney function are not routinely required for TB treatment unless the client has a preexisting renal impairment or is taking drugs that are nephrotoxic.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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