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 D
Explanation
A) This choice is incorrect because DVT is not caused by a bacterial infection in the blood vessels. It is primarily related to the formation of blood clots within the veins due to various risk factors.
B) This choice is incorrect because while injuries may be associated with DVT in some cases, they are not the primary cause. The formation of blood clots in the veins remains the underlying cause.
C) This choice is incorrect because atherosclerosis in the arteries is not the main cause of DVT. Atherosclerosis is a condition that involves the buildup of plaque in the arteries, not the veins.
D) This choice is correct. Deep vein thrombosis (DVT) is primarily caused by the formation of blood clots within the veins, typically in the lower extremities. These clots can obstruct blood flow and may lead to serious complications if not treated promptly.
Correct Answer is D
Explanation
A) This choice is incorrect because venous Doppler ultrasound is a non-invasive imaging test commonly used to diagnose DVT. However, it is not considered the gold standard due to potential limitations in visualizing small clots and deep veins.
B) This choice is incorrect because the D-dimer blood test is a screening test used to detect the presence of blood clot breakdown products. While it can help rule out DVT when negative, it is not the definitive diagnostic test.
C) This choice is incorrect because magnetic resonance imaging (MRI) is a sensitive imaging modality but is not considered the gold standard for diagnosing DVT. MRI may be used in specific cases, but contrast venography remains the gold standard.
D) This choice is correct. Contrast venography involves injecting contrast dye into the veins and taking X-ray images to visualize the blood flow and detect any clots. It is considered the gold standard for diagnosing DVT, as it provides direct visualization of the clot and the extent of its involvement.
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