A nurse is monitoring the laboratory values of a client who is receiving heparin. Which of the following values should the nurse report to the provider?
PT 11 seconds
APTT 50 seconds
Hematocrit 456
Platelets 300,000/mm²
The Correct Answer is C
A.PT (Prothrombin Time) 11 seconds: The prothrombin time measures the extrinsic pathway of the coagulation cascade. A PT of 11 seconds is within the normal range, and it indicates that the extrinsic clotting pathway is functioning appropriately. There is no need to report this value.
B. APTT (Activated Partial Thromboplastin Time) 50 seconds: The APTT measures the intrinsic pathway of the coagulation cascade. A value of 50 seconds is prolonged and may suggest that the client is receiving an effective anticoagulant dose. However, the APTT target range can vary based on the specific therapeutic goal and the heparin protocol in use. It's essential to follow the healthcare provider's guidance on the target APTT range.
C. Hematocrit 456: The normal range for hematocrit is usually expressed as a percentage. A value of 456 is outside the normal range and likely represents an error or a misinterpretation. The nurse should verify this value, as an extremely high hematocrit could be indicative of an issue such as dehydration or an analytical error.
D. Platelets 300,000/mm²: A platelet count of 300,000/mm² is within the normal range. There is no need to report this value as it suggests a normal platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Absence of deep-tendon reflexes:
Absence of deep-tendon reflexes is a sign of magnesium toxicity. Magnesium sulfate, when infused in high doses, can lead to neuromuscular blockade and affect reflexes. Discontinuing the infusion and administering calcium gluconate can counteract the effects of magnesium.
B. Urine output 80 mL in 4 hours:
Urine output is not a direct indicator of magnesium toxicity. Monitoring urine output is important for assessing renal function, but it is not a specific sign of magnesium toxicity.
C. Decreased level of consciousness:
Decreased level of consciousness is another sign of magnesium toxicity. Central nervous system depression is a potential adverse effect of elevated magnesium levels. Administering calcium gluconate can help antagonize the effects of magnesium.
D. Report of chills:
Chills are not typically associated with magnesium toxicity. This symptom may indicate other issues, such as infection or discomfort.
E. Systolic blood pressure 130 mm/Hg:
Systolic blood pressure within a normal range is not a sign of magnesium toxicity. Blood pressure changes are not typically the primary indicators of magnesium toxicity.
Correct Answer is A
Explanation
A. Rotate the application site every week (Correct Answer): This is the correct advice. Rotating the application site helps prevent skin irritation and enhances absorption. It's common practice to apply the patch to a different, clean, and hairless area of the skin each time it is changed.
B. The transdermal patch releases nicotine rapidly into the bloodstream: This statement is incorrect. The transdermal nicotine patch is designed to release nicotine gradually over an extended period. It provides a steady, controlled release of nicotine to help manage withdrawal symptoms and cravings.
C. Leave the patch in place for 8 hr each day: The specific duration for wearing a nicotine patch can vary depending on the product. However, it's generally recommended to wear the patch for 16 to 24 hours, depending on the product's instructions. Leaving it on for 8 hours only may not provide adequate coverage for the entire day.
D. The transdermal patch can cause insomnia: While insomnia is a potential side effect of nicotine replacement therapy, including the patch, it is not a universal experience for everyone. Insomnia is more likely to occur if the patch is worn continuously, including during the night. Following proper usage guidelines, such as removing the patch before bedtime, can help minimize this side effect.
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