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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Correct Answer is C

Explanation

A. Lethargy: Lethargy can be a nonspecific symptom of many conditions, including infection or general illness, but it is not a hallmark sign of gentamicin toxicity. While monitoring overall status is important, lethargy alone does not indicate ototoxicity or nephrotoxicity.

B. Weight gain: Weight gain may reflect fluid retention or other metabolic changes, but it is not a primary indicator of gentamicin toxicity. Nephrotoxicity could eventually cause fluid retention, but weight gain is a delayed and nonspecific finding.

C. Tinnitus: Tinnitus, or ringing in the ears, is a classic early sign of ototoxicity associated with aminoglycosides like gentamicin. It indicates damage to the inner ear and requires immediate assessment and potential discontinuation of the drug to prevent permanent hearing loss.

D. Slurred vision: Slurred vision is not typically associated with gentamicin toxicity. Visual changes are not a known adverse effect of aminoglycosides, so this finding would prompt evaluation for other causes rather than drug toxicity.

A. 1/2 cup raw carrots B. 3 or canned tuna C. 6 or low-fat yogurt D. 1 slice whole wheat bread

Correct Answer is C

Explanation

A. 1/2 cup raw carrots: Carrots contain minimal calcium, providing only a small fraction of the daily requirement. While nutritious, they are not an effective source for preventing or managing osteoporosis.

B. 3 oz canned tuna: Tuna is high in protein and omega-3 fatty acids but contains very little calcium. It does not contribute significantly to meeting daily calcium needs essential for bone health.

C. 6 oz low-fat yogurt: Yogurt is rich in calcium and often fortified with vitamin D, making it an excellent dietary source for promoting bone strength. Consuming yogurt helps maintain adequate calcium intake, which is critical for osteoporosis prevention and management.

D. 1 slice whole wheat bread: Whole wheat bread provides some nutrients, including fiber and small amounts of minerals, but its calcium content is low. It is not sufficient to meet the dietary calcium requirements needed to support bone health.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity?

Correct Answer is C

Explanation

A nurse is teaching a client who has osteoporosis about how to increase calcium in their diet. The nurse should instruct the client that which of the following foods is the best source of calcium?

Correct Answer is C

Explanation

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