A nurse is caring for a client receiving intravenous (IV) heparin therapy for deep vein thrombosis (DVT). What is the nurse's priority action to ensure safe administration of the medication?
Monitoring the client's prothrombin time (PT) and international normalized ratio (INR).
Assessing the client's liver function regularly.
Administering heparin via a central venous catheter.
Monitoring the client's activated partial thromboplastin time (aPTT).
The Correct Answer is D
A) This choice is incorrect because monitoring prothrombin time (PT) and international normalized ratio (INR) is more relevant to monitoring oral anticoagulant therapy (e.g., warfarin) and not intravenous heparin therapy.
B) This choice is incorrect because while liver function tests may be important for some medications, they are not the priority for clients on intravenous heparin therapy. Heparin is primarily eliminated by the kidneys.
C) This choice is incorrect because while administering heparin via a central venous catheter is possible, it is not the priority action for safe administration. Monitoring the client's response to heparin therapy is more important.
D) This choice is correct. Monitoring the client's activated partial thromboplastin time (aPTT) is the priority action when administering intravenous heparin. The aPTT reflects the client's response to heparin and helps adjust the dosage to achieve the desired therapeutic effect while minimizing the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This choice is correct. Encouraging active range of motion exercises helps prevent deep vein thrombosis (DVT) by promoting blood flow and reducing stasis in the veins. Moving the legs and ankles regularly helps prevent clot formation in immobilized clients.
B) This choice is incorrect because low-dose aspirin is not specifically indicated for preventing DVT. While aspirin may have some antiplatelet effects, it is not the primary preventive measure for DVT in high-risk clients.
C) This choice is incorrect because applying a heating pad to the affected leg is not a preventive measure for DVT. Heat application is not recommended for DVT prevention and could cause burns or injury.
D) This choice is incorrect because providing a soft mattress for the client's bed does not directly prevent DVT. The focus should be on encouraging movement and mobility to prevent DVT in clients at risk.
Correct Answer is A
Explanation
A) This choice is correct. Performing calf-stretching exercises in the aisle can help improve blood circulation in the legs during a long flight and reduce the risk of stasis and clot formation.
B) This choice is incorrect because using a heating pad on the legs during a flight may not be feasible or safe. It is not a recommended preventive measure for DVT.
C) This choice is incorrect because wearing compression stockings during the flight is a recommended preventive measure for DVT. Compression stockings help improve blood flow and reduce the risk of clot formation during prolonged immobility.
D) This choice is incorrect because taking prescribed anticoagulant medication before boarding a flight is not a recommended preventive measure for all clients. The decision to take anticoagulant medication before a flight should be based on the client's individual risk factors and medical history.
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