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 C
Explanation
Choice A rationale
While occlusive agents like Vaseline can smother lice, this method is messy and generally not as effective as targeted pediculicides. It mainly suffocates the live lice but does not consistently eliminate the nits (eggs), which are tightly attached to the hair shaft and must be removed to prevent reinfestation.
Choice B rationale
A soda-vinegar solution has no proven efficacy in eradicating lice. The acetic acid in vinegar can help loosen the glue-like substance that attaches nits to the hair shaft, but it is not a standalone treatment. Baking soda does not have any scientific basis for being effective against pediculosis.
Choice C rationale
A vinegar-water solution, specifically the acetic acid in vinegar, helps to dissolve the proteinaceous cement substance that glues nits to the hair shaft. This makes the nits easier to remove with a fine-toothed nit comb, which is a crucial step in the eradication process to prevent the hatching of new lice.
Choice D rationale
Dish detergents are not formulated to be effective against lice and can be harsh on the scalp, causing irritation. They lack the specific neurotoxic agents or suffocation properties found in approved pediculicide shampoos that are designed to kill lice and their eggs. This method is ineffective and potentially harmful. .
Correct Answer is B
Explanation
Choice A rationale
Steak and French fries are high in saturated and trans fats, which raise LDL cholesterol. The dietary management of elevated lipid panels focuses on reducing these fats to decrease cardiovascular risk. Iceberg lettuce offers minimal nutritional value.
Choice B rationale
Baked chicken breast is a lean protein source, and baking avoids adding unhealthy fats. Broccoli and tomatoes are rich in soluble fiber and antioxidants, which can help lower LDL cholesterol and improve overall cardiovascular health. This meal choice is consistent with a heart-healthy diet.
Choice C rationale
Fried catfish is cooked in oil, increasing its saturated fat content. Cornbread often contains high amounts of fat and sugar, contributing to poor lipid profiles. These food choices would not be considered beneficial for managing an elevated lipid panel.
Choice D rationale
Spaghetti with meat sauce often contains high-fat ground meat, contributing to saturated fat intake. Garlic bread is typically prepared with butter or margarine, adding more unhealthy fats. This meal is high in carbohydrates and fats and is not a good choice for managing lipids. .
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