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 C
Explanation
A. Skipped eating lunch would more likely cause hypoglycemia rather than diabetic ketoacidosis (DKA). When a person with type 1 diabetes skips a meal but still takes insulin, blood glucose levels drop, leading to hypoglycemia, not the elevated glucose and ketone production seen in DKA.
B. Incorrectly administered too much insulin would also result in hypoglycemia rather than DKA. Administering excessive insulin causes blood glucose levels to fall too low, which does not trigger the fat breakdown and ketone production that characterize DKA.
C. Had a cold and ear infection for the past two days is the most likely cause of diabetic ketoacidosis. Illness and infection cause the body to release stress hormones such as cortisol and adrenaline, which increase blood glucose levels and counteract insulin. In type 1 diabetes, insufficient insulin leads to hyperglycemia, fat breakdown for energy, and the production of ketones, resulting in DKA.
D. Ate an extra peanut butter sandwich before gym class would not cause DKA. Consuming extra food may raise blood glucose temporarily, but it would not lead to the severe insulin deficiency and ketone production seen in DKA, especially if the adolescent took insulin as prescribed.
Correct Answer is C
Explanation
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
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