The nurse is reviewing laboratory values for a client receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?
AST and ALT
Prothrombin time (PT)
Activated partial thromboplastin time (aPTT)
International normalized ratio (INR)
The Correct Answer is C
A. AST and ALT are liver enzymes, primarily used to assess liver function, not directly related to monitoring heparin therapy.
B. Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. Heparin therapy is typically monitored with aPTT, whereas warfarin is monitored with PT/INR.
C. Heparin is an anticoagulant that works by inhibiting clotting factors, and the aPTT is used to monitor its effectiveness. The aPTT measures the time it takes for blood to clot and helps ensure the heparin dose is therapeutic without causing excessive bleeding. The typical therapeutic range for aPTT on heparin therapy is 1.5 to 2.5 times the normal value.
D. INR is used to monitor warfarin therapy, not heparin. Heparin does not affect INR levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Warfarin is an anticoagulant, which increases the risk of bleeding. Activities like straining or forceful nose blowing can increase the risk of bleeding, particularly nasal or internal bleeding, so the nurse should advise the client to avoid these actions.
B. Brushing teeth vigorously is not recommended with warfarin because it can lead to bleeding gums. The nurse should suggest using a soft toothbrush and brushing gently.
C. If a dose of warfarin is missed, the client should not double the dose. They should take the missed dose as soon as they remember, unless it's close to the time for the next dose, in which case they should skip the missed dose and resume the normal dosing schedule.
D. Warfarin is an oral medication, so rotating injection sites is not applicable. This advice is more relevant for injectable medications like insulin or heparin.
Correct Answer is ["A","C","D"]
Explanation
A. Preventing injury is critical in PAD, as poor circulation makes it more difficult for the body to heal wounds. Injuries or cuts can lead to severe infections or ulcers, which may progress to amputation in severe cases.
B. Wearing tight compression stockings can worsen PAD by restricting blood flow. Loose-fitting stockings or compression socks may be beneficial, but tight stockings should be avoided.
C. Regular walking improves circulation in the legs and can help manage PAD. Resting when cramping occurs allows the muscles to receive blood flow again, reducing the risk of further damage.
D. Reducing intake of saturated fats, trans fats, and cholesterol is essential to prevent further progression of PAD, as these substances contribute to the buildup of plaque in the arteries, leading to narrowing and reduced blood flow.
E. Applying ice to the legs can worsen symptoms of PAD, as it may further restrict blood flow. Heat therapy may be more appropriate for pain relief, but this should be done cautiously to avoid burns or worsening circulatory issues.
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