A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (APTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?
Reference Range:
Activated Partial Prothromboplastin Time (APTT) [Anticoagulant therapy: 1.5 to 2 times the control value in seconds.] Prothromboplastin Time (PT) [Anticoagulant therapy: greater than 1.5 to 2 times the control value.] International Normalized Ratio (INR) [0.8 to 1.1]
Increase the warfarin dose.
Withhold the heparin and continue the same dose of warfarin.
Decrease the heparin dose.
D Increase the heparin dose and decrease the warfarin dose.
The Correct Answer is B
A) Incorrect - The APTT value being two times the control value indicates that the client's anticoagulation is within the therapeutic range. There is no need to increase the warfarin dose.
B) Correct - With the APTT value within the target range and the PT and INR values also normal, the nurse should continue the same dose of warfarin and withhold the heparin.
C) Incorrect - Decreasing the heparin dose is not indicated, as the client's APTT is already within the therapeutic range.
D) Incorrect - Increasing the heparin dose and decreasing the warfarin dose is not necessary, as the client's anticoagulation levels are appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.
Correct Answer is A
Explanation
This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.
The other options are not correct because:
B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.
C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.
D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.
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