A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?

Withhold the next dose of warfarin

Withhold the heparin infusion

Prepare to administer vitamin K

Prepare to administer alteplase

Answer and Explanation

The Correct Answer is B

A. Withholding the next dose of warfarin is incorrect. Warfarin takes several days to reach therapeutic levels, and the INR of 1.8 is below the target range (typically 2.0–3.0 for PE treatment). Stopping warfarin is unnecessary.
B. Withholding the heparin infusion is correct. The aPTT is significantly elevated at 98 seconds (therapeutic range: 60–80 seconds for PE treatment), increasing the risk of bleeding. The nurse should pause the heparin infusion and notify the provider for dose adjustment.
C. Preparing to administer vitamin K is incorrect. Vitamin K reverses warfarin effects, but the INR of 1.8 is not dangerously high and does not require reversal.
D. Preparing to administer alteplase is incorrect. Alteplase (a thrombolytic) is used for massive PE with hemodynamic instability, not for a patient already receiving anticoagulation therapy.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Making a referral for social services is appropriate as they can assist the client with discharge planning, home care services, and resources for palliative care to support the client's wishes.

B. While it is important to explain the risks of leaving against medical advice, the priority is to support the client’s desire to go home, rather than focusing on the potential consequences at this moment.

C. Contacting the facility chaplain could be beneficial for emotional support, but it does not address the immediate need for facilitating the client’s wish to go home.

D. Encouraging the client to continue with inpatient care contradicts their expressed desire to be with family, which is a crucial aspect of their emotional well-being in this situation.

A. Reports suspected child maltreatment to social services B. Notifies the health department of a client's diagnosis of chlamydia C. Tells the hospital chaplain a client's diagnosis D. Informs the provider about a client's suicide plan E. Reports suspected child maltreatment to social services

Correct Answer is C

Explanation

A. Reporting suspected child maltreatment is a legal and ethical responsibility of the nurse; this action is appropriate and does not require intervention.

B. Notifying the health department about a client's diagnosis of chlamydia is a legal requirement, as it is a reportable disease, so this action is appropriate.

C. Sharing a client’s diagnosis with a hospital chaplain without the client's consent could violate the client's confidentiality and requires intervention.

D. Informing the provider about a client's suicide plan is a critical action for patient safety and does not require intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse manager is assisting with the orientation of a newly licensed nurse. Which of the following actions by the nurse requires the nurse manager to intervene?

Correct Answer is C

Explanation

A nurse is caring for a client who is in labor at 39 weeks of gestation. During the second stage of labor, the nurse observes early decelerations on the monitor tracing. Which of the following actions should the nurse take?

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

. A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?