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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A therapeutic effect of naloxone is the reversal of opioid-induced respiratory depression, which is one of the most dangerous complications of opioid overdose. Naloxone works by binding to opioid receptors, displacing opioids, and restoring normal respiratory drive. An increase in respiratory rate after administration indicates that naloxone is effective.

Choice A is wrong because decreased blood pressure is not a therapeutic effect of naloxone.

In fact, naloxone can cause hypertension (high blood pressure) as a side effect due to opioid withdrawal.

Choice B is wrong because decreased nausea is not a therapeutic effect of naloxone. Nausea is a common side effect of morphine, but naloxone does not affect it directly.

Naloxone can actually cause nausea and vomiting as a side effect due to opioid withdrawal.

Choice D is wrong because increased pain relief is not a therapeutic effect of naloxone.

Pain relief is a desired effect of morphine, but naloxone antagonizes it by blocking the opioid receptors.

Naloxone can cause pain and discomfort as a side effect due to opioid withdrawal.

A. Discard the medication if it is yellow. B. Use a gravity flow set. C. Prime the tubing with 0.9% sodium chloride. D. Administer the medication over 2 hr.

Correct Answer is D

Explanation

The correct answer is d. Administer the medication over 2 hr.

Choice A reason: Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.

Choice B reason: Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.

Choice C reason: Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.

Choice D reason: Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering naloxone to a client who has developed an adverse reaction to morphine. The nurse should identify which of the following findings is a therapeutic effect of naloxone?

Correct Answer is C

Explanation

A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who has infective endocarditis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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