A client is receiving a continuous intravenous infusion of heparin for deep vein thrombosis. The nurse notes that the client's activated partial thromboplastin time (aPTT) is above the therapeutic range. Which of the following actions should the nurse take?

Stop the infusion and notify the provider.

Decrease the infusion rate and notify the provider.

Increase the infusion rate and notify the provider.

Continue the infusion and monitor the client.

Answer and Explanation

The Correct Answer is B

Heparin is an anticoagulant that inhibits clotting factors and prevents thrombus formation. The aPTT is a laboratory test that measures the effectiveness of heparin therapy. The therapeutic range for aPTT is usually 1.5 to 2 times the normal value, which is about 25 to 35 seconds. If the aPTT is above the therapeutic range, this indicates that the client is at risk for bleeding and that the heparin dose is too high.

A) This is not an appropriate action. Stopping the infusion abruptly could put the client is at risk for clotting and complications such as pulmonary embolism or stroke The nurse should only stop the infusion if instructed by the provider or if the client has signs of severe bleeding or haemorrhage.

B) Correct. This is an appropriate action. Decreasing the infusion rate will lower the heparin dose and bring the aPTT back to the therapeutic range. The nurse should notify the provider of the aPTT result and obtain further orders for heparin therapy.

C) This is not an appropriate action. Increasing the infusion rate will raise the heparin dose and increase the aPTT further above the therapeutic range. This could worsen the risk of bleeding for the client.

D) This is not an appropriate action. Continuing the infusion without adjusting the rate or notifying the provider could result in harm to the client due to excessive anticoagulation and bleeding.

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Correct Answer is A

Explanation

The nurse should notify the provider and document the interaction in the client's chart when a potential medication interaction is identified. The provider may need to adjust or change one or both of the medications to prevent if from harming the client.

A) Correct. This is the appropriate action for the nurse to take when a potential medication interaction is identified.

B) This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.

C) This is not an appropriate action. The nurse should not administer both medications as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.

D) This is not an appropriate action. The nurse should not rely on the client's self-report of problems with taking both medications. The client may not be aware of or recognize all of the possible signs and symptoms of a medication interaction.

A. Stop the infusion and remove the IV catheter. B. Apply a warm compress to the infusion site. C. Notify the provider and obtain an order for a different IV site. D. Slow down the infusion rate and monitor the client.

Correct Answer is A

Explanation

The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues.

The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.

b) Incorrect. This is an appropriate action after removing the IV catheter, but not before.

c) Incorrect. This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.

d) Incorrect. This is not an appropriate action because it could worsen the condition and increase the risk of complications.

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A client is receiving a continuous intravenous infusion of heparin for deep vein thrombosis. The nurse notes that the client's activated partial thromboplastin time (aPTT) is above the therapeutic range. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's medication list and notices that the client is taking two medications that have a potential interaction. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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