A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds (60 to 80 seconds). Which of the following actions should the nurse take first?

Turn off the heparin drip

Administer protamine sulfate

Repeat the aPTT now and in 1 hr

Obtain a portable chest x-ray

Answer and Explanation

The Correct Answer is A

A. Turn off the heparin drip: The client’s aPTT is significantly elevated and is accompanied by active bleeding, indicated by hematuria. Stopping the heparin infusion is the most immediate action because it removes the source of ongoing anticoagulation and helps prevent further bleeding. This stabilizes the situation before additional corrective measures are taken.

B. Administer protamine sulfate: Protamine sulfate is the reversal agent for heparin and may be required, but it should be given after the heparin infusion is stopped. Administering it without stopping the drip allows continued anticoagulation, reducing the effectiveness of the reversal. The reversal medication is a secondary intervention.

C. Repeat the aPTT now and in 1 hr: Rechecking coagulation labs is appropriate to monitor progress, but it does not address the immediate risk of ongoing bleeding. Delaying action while repeating labs can allow further anticoagulation and worsening hemorrhagic symptoms. Lab monitoring becomes relevant only after the heparin drip is stopped.

D. Obtain a portable chest x-ray: A chest x-ray would not address the current problem of excessive anticoagulation and active bleeding. There is no indication of a thoracic complication requiring imaging at this moment, and performing this step would delay urgent action. The priority is to stop the heparin and control bleeding.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Keep the head of the client's bed at a 15° angle: Elevating the head of the bed only slightly is insufficient for optimal lung expansion. A higher elevation, usually 30–45°, is recommended to improve ventilation and ease breathing during an exacerbation.

B. Place the client on bedrest for 24 hr: Prolonged bedrest can decrease lung expansion and increase the risk of mucus retention. Encouraging activity as tolerated helps maintain respiratory function and prevents complications.

C. Instruct the client to increase fluid intake to 2.5 L per day: Increased fluid intake helps thin secretions, making them easier to expectorate. This is a key intervention in managing an acute exacerbation of chronic bronchitis to improve airway clearance.

D. Encourage the client to perform deep-breathing exercises every 6 hr: Deep-breathing exercises are beneficial, but they should be performed more frequently than every 6 hours, often hourly or as tolerated, to effectively prevent atelectasis and improve oxygenation.

A. A client who has a history of MRSA will need antibiotics B. A client who has a history of MRSA can develop immunity to the infection. C. A client who has a history of MRSA requires a protective environment D. A client who has a history of MRSA can still transmit the infection

Correct Answer is D

Explanation

A. A client who has a history of MRSA will need antibiotics: Not all clients with a history of MRSA require antibiotics; treatment is only necessary if there is an active infection. Prophylactic antibiotics are not indicated solely based on past MRSA colonization or infection.

B. A client who has a history of MRSA can develop immunity to the infection: There is no immunity conferred by a past MRSA infection. Clients can be colonized or reinfected, and immunity does not prevent future transmission or infection.

C. A client who has a history of MRSA requires a protective environment: Protective environment precautions are used for immunocompromised clients to prevent them from acquiring infections, not for clients with MRSA history. MRSA requires standard and contact precautions, not protective isolation.

D. A client who has a history of MRSA can still transmit the infection: Clients with a history of MRSA may remain colonized and can transmit the bacteria to others, even if asymptomatic. Adhering to contact precautions and proper hand hygiene is essential to prevent spread within healthcare settings.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is having an exacerbation of chronic bronchitis. Which of the following interventions should the nurse plan to include?

Correct Answer is C

Explanation

A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA) Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. Which of the following should the nurse include in the teaching?

A nurse is assessing a client who has Parkinson's disease. Which of the following findings should the nurse identity as manifestations of this disease process? Select all that apply

A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose?

A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the dialysate outflow has become cloudy. Which of the following complications of this procedure should the nurse suspect?

A nurse receives change-of-shift report. Which of the following clients should the nurse attend to first?

A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?

A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding?

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?