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 D

Explanation

The most appropriate action for the nurse to take in this situation is:

d. Apply a warm, moist compress.

Here's why the other options are not recommended:

a. Initiate a new IV distal to the initial site:This is not the first course of action. While starting a new IV might be necessary eventually, it's crucial to address the issue at the current site first.
b. Slow the IV solution rate:Slowing the rate doesn't directly address the coolness and edema, which indicate potential infiltration or extravasation.
c. Maintain the extremity below the level of the heart:This action would actually worsen the edema by promoting fluid accumulation at the site.

Applying a warm, moist compress can help promote absorption of any leaked fluid and improve circulation at the site. However, it's important to remember that this is just one step in the process. The nurse should also:

Stop the IV infusion.
Assess the extent of the infiltration or extravasation.
Document the findings.
Elevate the affected extremity.
Consult with a physician for further instructions and potential treatment.

Correct Answer is ["0.4"]

Explanation

To calculate the amount of heparin to administer, use the formula:

mL of heparin=units available units ordered×1mL available

Substituting the values given in the question, we get:

mL of heparin=100004000×11=0.4

Therefore, the nurse should administer 0.4 mL of heparin.

Normal ranges for heparin therapy vary depending on the condition being treated and the laboratory method used to measure APTT.

A general range is 60 to 80 seconds or 1.5 to 2.5 times the control value.

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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 assessing a client’s IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["0.4"]

Explanation

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