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)

Exhibits

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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. "Lie down after meals.": Lying down after eating increases the risk of gastric contents refluxing into the esophagus due to gravity. Clients with GERD should remain upright for at least 2 to 3 hours after meals to minimize symptoms.
B. "Elevate the head of the bed while sleeping.": Elevating the head of the bed by 6 to 8 inches helps prevent nighttime reflux by using gravity to reduce backward flow of stomach acid into the esophagus, which is a key strategy in GERD management.
C. "Eat a snack 1 hour before going to bed.": Eating close to bedtime can exacerbate GERD symptoms by increasing gastric volume and acid production, especially when the client lies down soon after eating. A longer gap between the last meal and sleep is advised.
D. "Eat three large meals each day.": Large meals increase gastric pressure and acid production, worsening reflux symptoms. Clients with GERD should eat smaller, more frequent meals to reduce gastric distension and minimize acid reflux episodes.

A. Hypernatremia B. Decreased serum osmolality C. Ketones in the urine D. Hypoglycemia

Correct Answer is C

Explanation

Rationale:
A. Hypernatremia: While mild hypernatremia can occur in severe dehydration, it is not a defining or consistent feature of type 1 diabetes. Electrolyte imbalances may vary depending on hydration and glucose levels.

B. Decreased serum osmolality: In type 1 diabetes, serum osmolality is typically increased due to hyperglycemia and the osmotic effect of glucose in the bloodstream, which draws water out of cells and into the vascular space. A decrease would be inconsistent with the expected metabolic state.

C. Ketones in the urine: Ketones in the urine are a hallmark of type 1 diabetes, especially when insulin is deficient. Without insulin, the body breaks down fat for energy, producing ketones as a byproduct, which can be detected in the urine during diabetic ketoacidosis.

D. Hypoglycemia: Hypoglycemia is a complication of diabetes management, often resulting from too much insulin or missed meals. It is not a presenting manifestation of newly diagnosed type 1 diabetes, which typically presents with hyperglycemia and related symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?

Correct Answer is C

Explanation

A nurse in a community clinic is caring for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client should the nurse determine is the priority?

A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take?

A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

A nurse is monitoring a client who is receiving a unit of packed RBCs. Which of the following findings should the nurse identify as an indication that the client is having an allergic transfusion reaction?