A client is on intravenous heparin to treat DVT in the right leg. The client’s most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?

No change to the heparin rate

Decrease the heparin rate

Stop heparin and start warfarin

Increase the heparin rate

Answer and Explanation

The Correct Answer is D

Choice A reason: No change to the heparin rate is not appropriate in this scenario. The normal range for PTT is generally between 25 to 35 seconds. However, for a client on heparin therapy, the target PTT is typically 1.5 to 2.5 times the normal range, which would be approximately 60 to 80 seconds. Since the client’s PTT is only 25 seconds, it indicates that the blood is clotting too quickly, and the heparin dose is insufficient.

Choice B reason: Decreasing the heparin rate would further reduce the anticoagulant effect, which is not advisable given the current PTT of 25 seconds. Lowering the heparin rate could increase the risk of thrombus formation and worsen the deep vein thrombosis (DVT) condition.

Choice C reason: Stopping heparin and starting warfarin is not an immediate solution. Warfarin takes several days to achieve its full anticoagulant effect, and during this transition period, the client would be at risk of clot formation. Heparin provides immediate anticoagulation, which is crucial in the acute management of DVT.

Choice D reason: Increasing the heparin rate is the correct action. The current PTT of 25 seconds is below the therapeutic range for a client on heparin therapy. Increasing the heparin rate will help achieve the desired anticoagulant effect, prolonging the PTT to the target range of 60 to 80 seconds.

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Correct Answer is C

Explanation

Choice A Reason:

Assess the client’s oxygen saturation and, if normal, turn off the oxygen. This option is not ideal because turning off the oxygen completely can lead to a rapid drop in oxygen saturation levels, especially in patients who require continuous oxygen therapy. Monitoring oxygen saturation is crucial, but turning off the oxygen is not recommended unless specifically advised by a healthcare provider. Normal oxygen saturation levels typically range from 95% to 100%1. If the levels drop below 90%, it can lead to hypoxemia, which can cause serious complications.

Choice B Reason:

Have the client lift the mask off the face when taking bites of food. This option is also not ideal because it can be cumbersome for the client and may lead to inconsistent oxygen delivery. The Venturi mask is designed to provide a precise concentration of oxygen, and lifting it off repeatedly can disrupt this consistency. Additionally, it can be uncomfortable and impractical for the client to manage the mask while eating.

Choice C Reason:

Turn the oxygen off while the client eats the meal and then restart it. This option is not recommended for similar reasons as Choice A. Turning off the oxygen can lead to a significant drop in oxygen saturation levels, which can be dangerous for the client. Continuous oxygen therapy is essential for maintaining adequate oxygen levels in patients who require it. Interrupting this therapy, even temporarily, can have adverse effects on the client’s health.

Choice D Reason:

Determine if the client can switch to a nasal cannula during the meal. This is the best option because a nasal cannula allows the client to receive continuous oxygen while eating. The nasal cannula is less obtrusive and more comfortable for the client, enabling them to eat without significant interruption to their oxygen therapy. Nasal cannulas are commonly used for patients who need supplemental oxygen but also need to perform activities such as eating and talking. This approach ensures that the client maintains adequate oxygen levels while having their meal.

Correct Answer Reason:

Determine if the client can switch to a nasal cannula during the meal. This is the best option because a nasal cannula allows the client to receive continuous oxygen while eating. The nasal cannula is less obtrusive and more comfortable for the client, enabling them to eat without significant interruption to their oxygen therapy. Nasal cannulas are commonly used for patients who need supplemental oxygen but also need to perform activities such as eating and talking. This approach ensures that the client maintains adequate oxygen levels while having their meal.

A. High-flow nasal cannula B. Simple face mask C. Nasal cannula D. Non-rebreather mask E. Venturi mask

Correct Answer is ["B"]

Explanation

Choice A Reason: High-flow nasal cannula

The high-flow nasal cannula (HFNC) is designed to deliver oxygen at flow rates much higher than 5 liters per minute, typically ranging from 20 to 60 liters per minute. It is used for patients requiring high levels of oxygen and positive airway pressure. Therefore, it is not appropriate for a flow rate of 5 liters per minute.

Choice B Reason: Simple face mask

The simple face mask is suitable for delivering oxygen at flow rates between 6 to 10 liters per minute. However, it can also be used at a flow rate of 5 liters per minute, providing an FiO2 (fraction of inspired oxygen) of approximately 40-60%. This makes it an appropriate choice for the given requirement.

Choice C Reason: Nasal cannula

The nasal cannula is a low-flow oxygen delivery device that can deliver oxygen at flow rates from 1 to 6 liters per minute. At 5 liters per minute, it provides an FiO2 of approximately 40%. It is comfortable for patients and is commonly used for those who need a moderate amount of supplemental oxygen.

Choice D Reason: Non-rebreather mask

The non-rebreather mask is designed to deliver high concentrations of oxygen, typically at flow rates of 10 to 15 liters per minute. It is used in situations where patients need a high FiO2, close to 100%. Therefore, it is not suitable for a flow rate of 5 liters per minute.

Choice E Reason: Venturi mask

The Venturi mask is used to deliver precise oxygen concentrations, typically ranging from 24% to 60% FiO2. It is suitable for patients who require controlled oxygen therapy. While it can be adjusted to deliver oxygen at a flow rate of 5 liters per minute, it is generally used for more specific FiO2 requirements.

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A client is on intravenous heparin to treat DVT in the right leg. The client’s most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? Determine if the client can switch to a nasal cannula during the meal.

Correct Answer is C

Explanation

A client needs 5 liters of oxygen. Which of the following devices is appropriate for use with an oxygen flow rate of 5 liters? Select all that apply:

Correct Answer is ["B"]

Explanation

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