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 C

Explanation

Choice A reason: Administering a PRN narcotic at 9 cm dilation is inappropriate, as labor is in transition, nearing delivery. Narcotics risk fetal respiratory depression, crossing the placenta, especially with a stable fetal heart rate (120 beats/minute). Preparing for imminent delivery is critical, prioritizing a safe birth environment over pain relief.

Choice B reason: Asking the husband to leave does not address the client’s advanced labor (9 cm, 100% effaced, frequent contractions). His presence may provide support, and removal could increase distress. Setting up the delivery table is urgent, as birth is imminent, ensuring a sterile, safe environment for delivery.

Choice C reason: At 9 cm dilation, 100% effacement, and contractions every 2 minutes, the client is in transition, with delivery imminent. Setting up the delivery table ensures readiness for vaginal birth, providing a sterile field and equipment, addressing the physiological progression of labor for safe delivery of the newborn.

Choice D reason: Notifying the rapid response team is unnecessary, as the fetal heart rate (120 beats/minute) is normal (110–160), and screaming reflects labor pain. Delivery is imminent, making table setup the priority to facilitate safe birth, avoiding escalation to emergency response for a normal labor progression.

A. Place the client in a right lateral side-lying position and elevate the head of the bed. B. Compress the bulb with the tab open and then reinsert the tab into its opening. C. Irrigate the drain tubing with 1 mL of NS, then close the opening with its tab. D. Reinforce the incisional dressings and assess behind the neck for drainage.

Correct Answer is B

Explanation

Choice A reason: Positioning right lateral with head elevation may shift fluid but does not restore drain suction. Compressing the bulb creates negative pressure, promoting drainage. Positioning is less effective, per surgical drain management and postoperative care standards in nursing practice.

Choice B reason: Compressing the bulb with the tab open, then reinserting it, restores negative pressure, enhancing drainage in the surgical drain. This ensures fluid removal, preventing hematoma or infection, per evidence-based surgical drain management and postoperative care protocols in nursing practice.

Choice C reason: Irrigating the drain with saline risks infection and is not standard for low drainage. Compressing the bulb restores suction, promoting drainage safely. Irrigation is inappropriate, per surgical drain management and infection control standards in postoperative nursing care.

Choice D reason: Reinforcing dressings and assessing drainage addresses symptoms, not the cause of low drainage. Compressing the bulb restores suction, increasing drainage effectively. Dressings are secondary, per surgical drain management and postoperative wound care protocols in nursing practice.

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Naxlex Comprehensive Predictor Exams

A primigravida at 40 weeks gestation is contracting every 2 minutes, and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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?

Correct Answer is B

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?

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?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?