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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should follow the six rights of medication administration, which include the right client, right medication, right dose, right route, right time, and right documentation. The first action the nurse should take is to compare the medication label with the MAR to ensure that they match and that the medication has been prescribed for the client.
A) This is an important action, but not the first one. The nurse should check the client's identification band after comparing the medication label with the MAR and before administering the medication.
B) This is an important action, but not the first one. The nurse should explain the purpose and side effects of the medication after comparing the medication label with the MAR and before administering the medication.
C) Correct. This is the first action the nurse should take to ensure that the right medication is being given to the right client.
D) This is an important action, but not the first one. The nurse should assess the client for contraindications and allergies after comparing the medication label with the MAR and before administering the medication.
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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