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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Free Nursing Study Resources

Correct Answer is D

Explanation

The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.

A) This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.

B) This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.

C) This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.

D) Correct. This is an action to prevent medication errors by avoiding repeated injections in the same muscle group.

A. Check the medication label against the medication administration record (MAR) three times. B. Ask the client to state their name and date of birth before giving the medication. C. Use a barcode scanner to verify the client's identification band and the medication. D. Document the medication administration after completing other tasks. E. Follow the six rights of medication administration.

Correct Answer is ["A","B","C","E"]

Explanation

The nurse should check the medication label against the MAR three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also ask the client to state their name and date of birth and use a barcode scanner to verify the client's identification band and the medication. These are methods of ensuring that the right medication is given to the right client.

The nurse should follow the six rights of medication administration: right client, right medication, right dose, right route, right time, and right documentation.

The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.

a) Correct. This is one of the methods of ensuring medication safety.

b) Correct. This is another method of ensuring medication safety.

c) Correct. This is a third method of ensuring medication safety.

d) Incorrect. The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.

e) Correct. This is a general principle of medication safety.

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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 administering an intramuscular injection to a client. Which of the following actions should the nurse take to prevent medication errors?

Correct Answer is D

Explanation

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take to ensure medication safety? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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