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 ["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.

A. "I will use a soft-bristled toothbrush and an electric razor to prevent bleeding." B. "I will eat more green leafy vegetables to increase my vitamin K intake." C. "I will take ibuprofen instead of aspirin for pain relief." D. "I will check my blood pressure regularly while taking this medication."

Correct Answer is A

Explanation

Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors and increases the risk of bleeding. The client should use a soft-bristled toothbrush and an electric razor to prevent trauma and bleeding from minor cuts or abrasions.

A) Correct. This statement indicates that the client understands how to prevent bleeding while taking warfarin.

B) This statement indicates a lack of understanding of the teaching. The client should avoid sudden changes in vitamin K intake, as this can affect the therapeutic level of warfarin and increase the risk of clotting or bleeding. Green leafy vegetables are high in vitamin K and should be consumed in consistent amounts.

C) This statement indicates a lack of understanding of the teaching. The client should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen while taking warfarin, as they can increase the risk of bleeding. The client should consult with the provider before taking any over-the-counter medications for pain relief.

D) This statement indicates a lack of understanding of the teaching. Warfarin does not affect blood pressure directly but rather affects blood clotting. The client should monitor their international normalized ratio (INR), which measures the effectiveness of warfarin, regularly while taking this medication.

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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 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

A nurse is teaching a client who has a new prescription for warfarin about safe medication practices. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?

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

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?

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?