A client with a history of deep vein thrombosis (DVT) is receiving a continuous IV heparin infusion. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. Which action should the nurse take? Reference Range: aPTT [25 to 35 seconds, therapeutic range for heparin 1.5 to 2.5 times baseline, approximately 38 to 88 seconds].

Continue the heparin infusion at the current rate.

Increase the heparin infusion rate by 100 units/hour.

Stop the heparin infusion and notify the provider.

Administer protamine sulfate immediately.

Answer and Explanation

The Correct Answer is C

Choice A reason: Continuing heparin at aPTT 120 seconds is unsafe, as it exceeds the therapeutic range (38–88 seconds), indicating excessive anticoagulation. This risks bleeding, as heparin enhances antithrombin, inhibiting clotting factors. Stopping and notifying the provider prevents hemorrhage, making continuation dangerous for this DVT client.

Choice B reason: Increasing heparin is contraindicated with aPTT 120 seconds, far above therapeutic (38–88 seconds). Excessive anticoagulation from heparin’s antithrombin activation heightens bleeding risk. Stopping the infusion and notifying the provider corrects over-anticoagulation, preventing complications like hematoma, making an increase harmful and inappropriate.

Choice C reason: Stopping heparin and notifying the provider is critical at aPTT 120 seconds, indicating over-anticoagulation. Heparin’s inhibition of clotting factors increases bleeding risk in DVT treatment. Halting infusion prevents hemorrhage, and provider notification ensures dose adjustment or reversal, addressing the pathophysiological risk effectively and promptly.

Choice D reason: Administering protamine sulfate reverses heparin but requires provider order, as aPTT 120 seconds indicates high bleeding risk. Stopping infusion first prevents further anticoagulation, and notifying the provider ensures guided reversal, avoiding premature protamine use, which risks anaphylaxis or thrombosis, making this less immediate.

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Correct Answer is A

Explanation

Choice A reason: Questioning about related symptoms (e.g., urgency, frequency) clarifies nocturia and hesitancy, suggesting causes like benign prostatic hyperplasia. This comprehensive data guides targeted assessments, ensuring accurate diagnosis and treatment, per urological assessment and patient history standards in elderly male nursing care.

Choice B reason: Palpating for an inguinal bulge assesses hernia, unrelated to nocturia or hesitancy. Questioning related symptoms better identifies urinary issues, guiding diagnosis. Hernias are not primary causes, per urological assessment and differential diagnosis protocols in nursing care for urinary complaints.

Choice C reason: Inspecting the meatus for abnormalities or discharge may follow but is less comprehensive than symptom questioning, which broadens the urinary history. Symptoms like hesitancy suggest internal issues, per urological assessment and benign prostatic hyperplasia diagnostic standards in nursing practice for elderly men.

Choice D reason: Observing scrotal swelling assesses testicular issues, not directly linked to nocturia or hesitancy. Questioning symptoms like weak stream or dribbling prioritizes urinary tract evaluation, per urological and geriatric assessment protocols in nursing care for male urinary symptoms.

A. Withhold the dose until insulin regular is available on the unit. B. Withdraw 10 units regular insulin from the 70/30 vial. C. Pull up 30 units from the 70/30 vial, but only administer one third. D. Obtain a new vial of regular insulin and withdraw 10 units.

Correct Answer is D

Explanation

Choice A reason: Withholding the dose delays glucose control, risking hyperglycemia. Obtaining regular insulin ensures accurate dosing, as 70/30 cannot be separated. Timely administration is critical, per diabetes management and insulin therapy protocols in nursing practice for glycemic control.

Choice B reason: Withdrawing regular insulin from a 70/30 vial is impossible, as it’s a fixed mixture. Obtaining a regular insulin vial ensures precise 10-unit dosing, preventing errors, per medication safety and insulin administration standards in diabetes nursing care.

Choice C reason: Pulling 30 units of 70/30 and giving one third is unsafe, as it delivers mixed insulins, not just regular insulin. Obtaining regular insulin ensures accurate dosing, per insulin therapy and patient safety protocols in diabetes management nursing practice.

Choice D reason: Obtaining a new vial of regular insulin ensures the precise 10-unit dose, as 70/30 is a fixed mixture unsuitable for separating regular insulin. This prevents dosing errors, per evidence-based insulin administration and medication safety standards in diabetes nursing care.

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Naxlex Comprehensive Predictor Exams

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

Correct Answer is A

Explanation

Based on the capillary glucose measurement, a client is to receive 10 units of regular insulin. The client’s medication drawer contains one vial of a 70/30 mixture of regular insulin and isophane insulin. How should the nurse prepare the prescribed dose?

Correct Answer is D

Explanation

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Which nursing intervention is most effective in determining the severity of a client’s pain?

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?