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: 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. Change the tracheostomy ties every 48 hours. B. Suction the tracheostomy every 2 hours routinely. C. Assess airway patency every shift. D. Clean the inner cannula with hydrogen peroxide daily.

Correct Answer is C

Explanation

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy 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

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?

Correct Answer is C

Explanation

A client with chronic kidney disease (CKD) is prescribed a low-potassium diet. Which food choice indicates to the nurse that the client understands the dietary restrictions?

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)].

A client newly diagnosed with eczema tells the clinic nurse of using a heat lamp to dry the fluid-filled blisters localized in the left antecubital area. How should the nurse respond?

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?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male 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?

A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?