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 D
Explanation
A. "If I were you, I would get the vaccine to keep my family safe:"
This statement imposes the nurse's personal opinion on the client and may not respect the client's autonomy and decision-making.
B. "Influenza can be very serious to anyone who does not receive the vaccine:"
While this statement conveys the seriousness of influenza, it may be perceived as coercive or fear-inducing. It is important to provide information without pressure.
C. "The influenza vaccine is mandatory for all clients before discharge, so you will need to sign an against medical advice form:"
This statement is not accurate and may create unnecessary tension. Influenza vaccination is generally not mandatory, and clients have the right to decline without being labeled against medical advice for this particular vaccination.
D. "The influenza vaccine is strongly encouraged, but I understand you would like to decline right now:"
This is the correct answer. It acknowledges the client's decision to decline the vaccine while expressing that the vaccine is encouraged. It respects the client's autonomy and allows for open communication about the decision.
Correct Answer is A
Explanation
A. Visual disturbances:
Visual disturbances, such as blurred or yellow-tinted vision, are common signs of digoxin toxicity. Clients should report any changes in vision promptly.
B. Potassium 4.4 mEq/L:
While electrolyte imbalances, particularly low potassium levels, can increase the risk of digoxin toxicity, a potassium level of 4.4 mEq/L is within the normal range and, by itself, does not indicate digoxin toxicity.
C. Insomnia:
Insomnia is not a typical sign of digoxin toxicity. Symptoms of toxicity are more likely to involve the gastrointestinal and visual systems.
D. Sudden weight gain:
Sudden weight gain can be a symptom of heart failure exacerbation but is not a direct indication of digoxin toxicity. Other signs, such as visual disturbances, are more specific to digoxin toxicity.
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