A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?
INR 0.8, aPTT 85 seconds.
INR 2, aPTT 60 seconds.
The Correct Answer is B
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should maintain the client in a semi-Fowler's position to promote comfort and reduce the risk of complications related to appendicitis. This position helps to decrease pressure on the abdomen and may alleviate pain by reducing tension on the abdominal muscles.
Choice B rationale:
Administering an enema 1 hour prior to surgery is not indicated for a client with appendicitis. Enemas are generally not recommended for clients with suspected or confirmed appendicitis as they can potentially worsen inflammation and cause perforation of the inflamed appendix.
Choice C rationale:
Applying a warm pack to the client's lower abdomen is contraindicated in appendicitis. Heat can exacerbate inflammation and should be avoided in such cases.
Choice D rationale:
Placing the client on a clear liquid diet is not appropriate for appendicitis. Clients with appendicitis are typically NPO (nothing by mouth) to avoid stimulating the gastrointestinal tract and reduce the risk of rupture if surgery is needed.
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