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
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
Gastric bleeding can occur due to peptic ulcer disease, nonsteroidal anti inflammatory drugs (NSAIDs), or anticoagulants.
Choice C is wrong because cough is not a common adverse effect of morphine administered via continuous epidural infusion.
Cough can be caused by respiratory infections, asthma, or chronic obstructive pulmonary disease (COPD).
Choice D is wrong because tachypnea is not a common adverse effect of morphine administered via continuous epidural infusion.
Tachypnea can be caused by hypoxia, anxiety, pain, or fever. Morphine can cause respiratory depression, which is characterized by bradypnea, not tachypnea.
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