A nurse is teaching a female client about alcohol intake and how it affects hypertension.
The client asks if drinking two beers a night is an acceptable intake.What answer by the nurse is best?

Choice A rationale

While occlusive agents like Vaseline can smother lice, this method is messy and generally not as effective as targeted pediculicides. It mainly suffocates the live lice but does not consistently eliminate the nits (eggs), which are tightly attached to the hair shaft and must be removed to prevent reinfestation.

Choice B rationale

A soda-vinegar solution has no proven efficacy in eradicating lice. The acetic acid in vinegar can help loosen the glue-like substance that attaches nits to the hair shaft, but it is not a standalone treatment. Baking soda does not have any scientific basis for being effective against pediculosis.

Choice C rationale

A vinegar-water solution, specifically the acetic acid in vinegar, helps to dissolve the proteinaceous cement substance that glues nits to the hair shaft. This makes the nits easier to remove with a fine-toothed nit comb, which is a crucial step in the eradication process to prevent the hatching of new lice.

Choice D rationale

Dish detergents are not formulated to be effective against lice and can be harsh on the scalp, causing irritation. They lack the specific neurotoxic agents or suffocation properties found in approved pediculicide shampoos that are designed to kill lice and their eggs. This method is ineffective and potentially harmful. .

Choice A rationale

Regular assessment for bleeding is critical because heparin inhibits the coagulation cascade by enhancing antithrombin III, which inactivates thrombin and factor Xa. This increases the risk of hemorrhage, so the nurse must monitor for signs like petechiae, ecchymosis, hematuria, or GI bleeding to prevent serious complications. Platelets should be maintained above 100,000.

Choice B rationale

The activated partial thromboplastin time (aPTT) measures the time it takes for a fibrin clot to form via the intrinsic and common pathways of the coagulation cascade. Heparin therapy is monitored by the aPTT, with a therapeutic range typically 1.5 to 2.5 times the client’s baseline or control value, usually 45-75 seconds.

Choice C rationale

Stopping an IV heparin infusion for an aPTT above baseline is not always the correct action, as the therapeutic range is purposefully elevated. The aPTT should be 1.5 to 2.5 times the control value. An aPTT above this therapeutic range warrants holding the dose or adjusting the rate according to established hospital protocols and provider orders.

Choice D rationale

Using an IV pump is essential for heparin infusion to ensure precise and consistent administration. Heparin is a high-alert medication with a narrow therapeutic index. An IV pump prevents boluses and ensures the client receives the exact prescribed dose over time, minimizing the risk of subtherapeutic levels or overdose.

Choice E rationale

Daily weighing is crucial for monitoring fluid balance and detecting fluid shifts, which can indicate internal bleeding, a significant risk with heparin. Using the same scale at the same time each day, with the client wearing similar clothing, ensures accurate and comparable measurements, providing a reliable trend of the client’s weight.