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. Prolonged sitting or standing in one position can lead to reduced blood flow and stasis, increasing the risk of DVT. Encouraging regular movement and changing positions can help prevent clot formation.
B) This choice is incorrect because massaging the legs may not be suitable for everyone and is not a primary preventive measure for DVT. While it can aid in improving blood circulation, it should be done cautiously and not as a standalone preventive action.
C) This choice is incorrect because increasing the intake of vitamin K-rich foods is not a preventive measure for DVT. Vitamin K is involved in the clotting process, but it does not directly impact the risk of DVT.
D) This choice is incorrect because taking over-the-counter pain medications for leg discomfort does not prevent DVT. While pain management may be necessary for symptomatic relief, it does not address the underlying risk factors for DVT.
Correct Answer is B
Explanation
A) This choice is incorrect because while relieving leg pain and swelling is an important aspect of DVT treatment, the primary goal is to prevent the clot from dislodging and causing a pulmonary embolism or other complications.
B) This choice is correct. The primary goal of DVT treatment is to prevent the clot from dislodging and traveling to the lungs, where it can cause a potentially life-threatening pulmonary embolism. Anticoagulant therapy and other interventions are used to stabilize the clot and prevent its migration.
C) This choice is incorrect because eliminating the risk factors for DVT is not the primary goal of treatment for a client who already has DVT. Preventing clot progression and complications take precedence over addressing risk factors at this stage.
D) This choice is incorrect because while administering anticoagulant therapy is a common treatment for DVT, it is a specific intervention rather than the primary goal. Anticoagulants help prevent the clot from growing and reduce the risk of embolism.
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