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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A reason: Obtaining another blood pressure measurement is critical, as lethargy, pallor, and diaphoresis suggest hypotension or shock, despite the earlier 140/90 reading. This guides safe administration of antihypertensives, preventing harm, per cardiovascular assessment and medication safety protocols in nursing practice.

Choice B reason: Determining recent medications is important but secondary to assessing current blood pressure, as symptoms suggest acute instability. Blood pressure confirms hypotension risk before reviewing drugs, ensuring timely intervention, per cardiovascular assessment and patient safety standards in nursing care.

Choice C reason: Administering antihypertensives without reassessing blood pressure is unsafe, as lethargy, pallor, and diaphoresis indicate possible hypotension. Confirming blood pressure prevents exacerbating instability, per medication safety and cardiovascular monitoring protocols in nursing practice for clients with hypertension.

Choice D reason: Consulting the PN about the 0800 condition delays immediate assessment of current symptoms. Blood pressure measurement addresses acute lethargy, pallor, and diaphoresis, guiding intervention. Consultation is secondary, per prioritization and cardiovascular assessment standards in nursing care.

A. Red blood cell count of 3.5 x 10⁶/µL (3.5 x 10¹²/L). B. White blood cell count of 1,500/mm³ (1.5 x 10⁹/L). C. Hematocrit of 33% (0.33 volume fraction). D. Hemoglobin of 10 g/dL (6.21 mmol/L).

Correct Answer is B

Explanation

Choice A reason: A red blood cell count of 3.5 x 10⁶/µL indicates anemia from myelosuppression, reducing oxygen transport. RBCs do not fight infection, so this does not support “risk for infection.” Low WBCs impair immune defense, increasing infection susceptibility, making WBC count more relevant to the nursing problem in this context.

Choice B reason: A WBC count of 1,500/mm³ indicates severe leukopenia from myelosuppression, reducing neutrophil production. This impairs immune response, significantly raising infection risk, as pathogens overwhelm the body’s defenses. This lab value directly supports “risk for infection,” necessitating precautions like isolation or antibiotics to prevent opportunistic infections.

Choice C reason: Hematocrit of 33% reflects anemia in myelosuppression, lowering oxygen delivery. This causes fatigue but does not increase infection risk, as RBCs are not immune cells. WBCs, particularly neutrophils, are critical for infection defense, making low WBC count more relevant to the nursing problem than hematocrit.

Choice D reason: Hemoglobin of 10 g/dL indicates anemia, reducing oxygen-carrying capacity in myelosuppression. This does not directly increase infection risk, as hemoglobin is not involved in immunity. Low WBCs compromise pathogen defense, making WBC count the key value supporting “risk for infection” in this client’s care plan.

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Naxlex Comprehensive Predictor Exams

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?