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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. This area is the lateral side of the the heel and is more commonly affected by arterial ulcers or pressure injuries. It is not the typical location for ulcers caused by venous insufficiency.

B. This area is the area on the tip of toes and is not a typical site for venous ulcers. Ulcers in this location are commonly arterial or diabetic ulcers.

C. This area is the area on the sole of the feet at the base of the big toe and is not a typical site for venous ulcers.
D. This area is the medial malleolus, just above the inner ankle, which is the most common site for venous ulcers. Chronic venous insufficiency leads to venous stasis and increased pressure in this region, causing skin breakdown and ulceration.

A. Maintain the head of the bed greater than 45°. B. Place a donut-shaped cushion under the client’s sacrum. C. Massage bony prominences three times daily. D. Apply moisturizer to damp skin after bathing.

Correct Answer is D

Explanation

Rationale:
A. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk.

B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution.

C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma.

D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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