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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client should stay upright for at least 15 minutes after taking ferrous gluconate to prevent oesophagal irritation. Choice B is wrong because taking an antacid with ferrous gluconate can decrease its absorption and effectiveness.
Choice C is wrong because taking ferrous gluconate with milk can also reduce its absorption and cause gastrointestinal distress.
Choice D is wrong because black stools are a common and harmless side effect of ferrous gluconate and do not indicate a need to notify the provider. Ferrous gluconate is an iron supplement used to treat or prevent iron deficiency anaemia, a condition where the body does not have enough red blood cells to carry oxygen to the tissues.
Iron is an essential component of haemoglobin, the protein that carries oxygen in the blood.
Correct Answer is D
Explanation
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
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