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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A report of chest pain is an adverse effect of epinephrine, which can increase myocardial oxygen demand and cause angina or myocardial ischemia.

B. Hypotension is not a common effect after administering epinephrine; it typically causes hypertension due to vasoconstriction.

C. Ecchymosis is not a known adverse effect of epinephrine and may be related to other factors.

D. Tinnitus is not a recognized adverse effect of epinephrine and does not commonly occur after administration.

A. Decreased cholesterol B. Decreased blood pressure C. Decreased esophageal reflux D. Decreased hallucinations

Correct Answer is D

Explanation

A. Decreased cholesterol is not a primary effect of chlorpromazine; the medication is primarily used for psychiatric conditions, not lipid management.

B. While chlorpromazine may have sedative effects that could impact blood pressure, decreased blood pressure is not a direct indicator of its effectiveness in treating psychiatric symptoms.

C. Decreased esophageal reflux is not a relevant effect of chlorpromazine, as it is primarily used for managing psychotic symptoms.

D. Decreased hallucinations is a direct indication of the medication's effectiveness in treating conditions such as schizophrenia or other psychotic disorders, as chlorpromazine is an antipsychotic medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is performing an admission assessment of a preschooler who is in the acute phase of Kawasaki disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

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 in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?