A nurse is caring for a female client who has deep-vein thrombosis (DVT) and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb)
Using the client information provided, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.)
Stop the heparin infusion for 1 hr.
Increase the rate of the infusion by 160 units/hr.
Administer heparin 2,400 unit IV bolus.
Continue the infusion without change.
The Correct Answer is A
Rationale:
A. Stop the heparin infusion for 1 hr: The client’s aPTT is 105 seconds, which is above the protocol threshold of >95 seconds. Per the titration guidelines, the nurse should hold the infusion for 60 minutes and decrease the rate by 3 units/kg/hr after the hold to reduce bleeding risk.
B. Increase the rate of the infusion by 160 units/hr: Increasing the infusion is appropriate only when aPTT is between 30–49 seconds. Since this client's aPTT is elevated, increasing the rate would further prolong clotting time and increase the risk of hemorrhage.
C. Administer heparin 2,400 unit IV bolus: Bolus doses are prescribed only for low aPTT values (30–49 seconds). Giving a bolus when aPTT is elevated can worsen anticoagulation and significantly increase the potential for bleeding complications.
D. Continue the infusion without change: Continuing the infusion is appropriate when aPTT is within the therapeutic range (50–70 seconds). This client’s aPTT is well above that range, indicating excessive anticoagulation that requires adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Place monitoring cords and tubes in a stockinette: Clients with latex allergies are at risk for serious reactions from contact with latex-containing equipment. Covering cords and tubing with a stockinette helps prevent direct skin exposure to latex, reducing the risk of an allergic reaction.
B. Schedule the client for the last surgery of the day: Clients with latex allergies should be scheduled as the first surgery of the day to minimize their exposure to airborne latex particles and reduce contamination from previously used equipment or surfaces.
C. Choose rubber injection ports for fluid administration: Rubber injection ports often contain latex, which can trigger severe allergic reactions. For clients with latex allergies, non-latex or latex-free alternatives must be used for all fluid and medication administration.
D. Have phenytoin IV readily available: Phenytoin is an anticonvulsant used to manage seizures and is not specifically indicated for treating allergic reactions. Epinephrine, antihistamines, and corticosteroids should be available in case of an anaphylactic reaction.
Correct Answer is A
Explanation
Rationale:
A. Respiratory alkalosis: The pH is elevated at 7.48, and the PaCO₂ is decreased at 30 mm Hg, indicating a loss of carbon dioxide due to hyperventilation. The HCO₃ is within normal range, confirming the imbalance is respiratory in origin. This pattern reflects respiratory alkalosis, which is commonly caused by anxiety-induced hyperventilation.
B. Respiratory acidosis: Respiratory acidosis is characterized by low pH and elevated PaCO₂. In this case, the pH is high and PaCO₂ is low, which is the opposite pattern of respiratory acidosis.
C. Metabolic alkalosis: Metabolic alkalosis involves an elevated pH with an increased HCO₃. While this client’s pH is elevated, their HCO₃ is normal, making a metabolic cause unlikely.
D. Metabolic acidosis: Metabolic acidosis presents with a decreased pH and decreased HCO₃. The client’s pH is high and HCO₃ is within the normal range, ruling out this imbalance.
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