A nurse is caring for a client on an IV infusion of heparin.
What actions does this nurse include in the client's plan of care? (Select all that apply.)
Assess the client for bleeding.
Monitor the daily activated partial thromboplastin time (aPTT) results.
Stop the IV for aPTT above baseline.
Use an IV pump for the infusion.
Correct Answer : A,B,D,E
Choice A rationale
Regular assessment for bleeding is critical because heparin inhibits the coagulation cascade by enhancing antithrombin III, which inactivates thrombin and factor Xa. This increases the risk of hemorrhage, so the nurse must monitor for signs like petechiae, ecchymosis, hematuria, or GI bleeding to prevent serious complications. Platelets should be maintained above 100,000.
Choice B rationale
The activated partial thromboplastin time (aPTT) measures the time it takes for a fibrin clot to form via the intrinsic and common pathways of the coagulation cascade. Heparin therapy is monitored by the aPTT, with a therapeutic range typically 1.5 to 2.5 times the client’s baseline or control value, usually 45-75 seconds.
Choice C rationale
Stopping an IV heparin infusion for an aPTT above baseline is not always the correct action, as the therapeutic range is purposefully elevated. The aPTT should be 1.5 to 2.5 times the control value. An aPTT above this therapeutic range warrants holding the dose or adjusting the rate according to established hospital protocols and provider orders.
Choice D rationale
Using an IV pump is essential for heparin infusion to ensure precise and consistent administration. Heparin is a high-alert medication with a narrow therapeutic index. An IV pump prevents boluses and ensures the client receives the exact prescribed dose over time, minimizing the risk of subtherapeutic levels or overdose.
Choice E rationale
Daily weighing is crucial for monitoring fluid balance and detecting fluid shifts, which can indicate internal bleeding, a significant risk with heparin. Using the same scale at the same time each day, with the client wearing similar clothing, ensures accurate and comparable measurements, providing a reliable trend of the client’s weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The presence of white flakes that are difficult to brush off the hair is a classic sign of pediculosis capitis, also known as head lice. These flakes are nits, or lice eggs, which are cemented to the hair shaft and are not easily removed. The rash on the back of the neck is often a result of scratching or an allergic reaction to the lice saliva.
Choice B rationale
Impetigo contagiosa is a highly contagious bacterial skin infection characterized by red sores that quickly rupture, ooze for a few days, and then form a honey-colored crust. It typically does not present with white flakes in the hair.
Choice C rationale
Folliculitis is an inflammation of the hair follicles, often caused by a bacterial or fungal infection. It presents as small, red pimples with a hair in the center. It is not associated with white flakes or nits in the hair.
Choice D rationale
Tinea capitis, a fungal infection of the scalp, is characterized by scaly patches of temporary baldness. It may cause inflammation and itching, but it does not produce the characteristic white flakes or nits that adhere to the hair shaft.
Correct Answer is A
Explanation
Choice A rationale
The presentation of scratching and rubbing white ridges between the fingers and on the wrists is a classic sign of a parasitic mite infestation, specifically scabies. Scabies is caused by Sarcoptes scabiei mites that burrow into the skin. Permethrin is a topical insecticide that is the first-line treatment for scabies because it effectively kills the mites and their eggs.
Choice B rationale
Administering an antihistamine would address the symptom of itching, which is a common manifestation of scabies due to the body's allergic reaction to the mites and their feces. However, it does not treat the underlying cause, which is the parasitic infestation. Antihistamines provide symptomatic relief but will not eradicate the mites, allowing the infestation to persist and potentially spread.
Choice C rationale
Assessing the client's airway is an intervention for a client experiencing an anaphylactic reaction or other respiratory distress. Scabies is a dermatological condition and does not pose a direct threat to a client's airway unless the client has a severe and rare allergic reaction. This action is not relevant to the presenting signs and symptoms of scabies.
Choice D rationale
Applying gloves to minimize friction would not address the underlying pathology of scabies. The purpose of this intervention is to protect the skin from further mechanical damage, but it does not treat the parasitic cause of the condition. While gloves may prevent some scratching, they do not eradicate the mites and are not a primary treatment. .
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