A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?
Increased pulse rate.
Increased blood pressure.
Decreased temperature.
Decreased respiratory rate.
The Correct Answer is A
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Increased pulse rate.
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
Correct Answer is B
Explanation
According to the CDC, people with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine. However, people with egg allergy can get a flu vaccine. The CDC also states that people who have had a severe allergic reaction to a dose of influenza vaccine should not get that flu vaccine again and might not be able to receive other influenza vaccines. Therefore, a nurse should report an egg allergy to the provider as a possible contraindication to receiving the vaccine.
Choice A is wrong because shellfish is not an ingredient in a flu vaccine and is not a contraindication to receiving the vaccine.
Choice C is wrong because milk is not an ingredient in a flu vaccine and is not a contraindication to receiving the vaccine.
Choice D is wrong because peanuts are not an ingredient in a flu vaccine and are not a contraindication to receiving the vaccine.
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