A nurse is caring for a client receiving intravenous heparin. Which of the following laboratory values should the nurse monitor to assess the client's response to therapy?
Prothrombin time (PT)
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Platelet count
The Correct Answer is C
C) Correct. Heparin primarily affects the intrinsic pathway of the coagulation cascade, and the activated partial thromboplastin time (aPTT) is the laboratory test used to monitor the client's response to heparin therapy. The aPTT provides information about the time it takes for the client's blood to clot and helps determine the appropriate heparin dosage.
A) Incorrect. Prothrombin time (PT) is used to monitor clients receiving warfarin therapy, not heparin.
B) Incorrect. International normalized ratio (INR) is also used to monitor clients receiving warfarin therapy, not heparin.
D) Incorrect. Platelet count is important to monitor for heparin-induced thrombocytopenia (HIT), a potential adverse effect of heparin therapy, but it does not directly assess the client's response to heparin therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Correct. Clients taking warfarin should continue to eat foods high in vitamin K, but they should try to keep their intake consistent. Vitamin K plays a role in the synthesis of clotting factors, and warfarin works by inhibiting the action of vitamin K, thereby reducing the blood's ability to clot. Consistent vitamin K intake helps maintain a stable response to warfarin.
A) Incorrect. Avoiding foods high in vitamin K is not necessary, but consistency in vitamin K intake is important.
C) Incorrect. Increasing intake of foods high in vitamin K can counteract the effects of warfarin and increase the risk of blood clots.
D) Incorrect. Consuming unlimited amounts of foods high in vitamin K can interfere with the anticoagulant effects of warfarin and lead to inconsistent therapeutic response.
Correct Answer is A
Explanation
A) Correct. Digoxin is a cardiac glycoside, and hypokalemia increases the risk of digoxin toxicity. A serum potassium level of 3.2 mEq/L indicates hypokalemia and requires immediate nursing intervention. Hypokalemia can potentiate the effects of digoxin on cardiac conduction, leading to dysrhythmias.
B) Incorrect. A heart rate of 60 beats per minute is within the expected range for a client taking digoxin, as it is commonly used to control heart rate in certain cardiac conditions.
C) Incorrect. A systolic blood pressure of 100 mmHg may be within an acceptable range for a client with heart failure, depending on their baseline blood pressure and symptoms. It does not require immediate nursing intervention.
D) Incorrect. A digoxin level of 1.2 ng/mL is within the therapeutic range for digoxin. It does not require immediate nursing intervention.
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