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 B
Explanation
A) This choice is incorrect because arterial blood gas (ABG) analysis assesses oxygen and carbon dioxide levels in the blood, primarily used for respiratory and acid-base evaluations, not for confirming DVT.
B) This choice is correct. The D-dimer blood test is a screening test used to detect the presence of blood clot breakdown products in the blood. Elevated levels of D-dimer may suggest the presence of a blood clot, prompting further diagnostic testing for DVT.
C) This choice is incorrect because an electrocardiogram (ECG) primarily assesses the electrical activity of the heart and is not specific to confirming DVT. It may be useful to assess cardiac function in individuals with suspected pulmonary embolism.
D) This choice is incorrect because a chest X-ray is not used to confirm DVT. It is helpful in assessing the lungs and heart, particularly for detecting potential complications of DVT like a pulmonary embolism, but it does not directly diagnose DVT.
Correct Answer is D
Explanation
A) This choice is incorrect because compression stockings do not dissolve existing blood clots. Their primary purpose is to prevent new blood clots from forming by aiding blood flow and preventing stasis in the veins.
B) This choice is incorrect because while compression stockings may help reduce swelling in the affected leg by supporting venous return, their primary function is to prevent DVT and not specifically address swelling.
C) This choice is incorrect because compression stockings primarily target venous circulation in the legs and do not directly improve blood circulation throughout the entire body.
D) This choice is correct. Compression stockings exert pressure on the legs, assisting in venous return and preventing blood from pooling and clot formation. They are used as a preventive measure for individuals at risk of DVT or those diagnosed with DVT to reduce the risk of complications and recurrence.
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