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

Medication reconciliation is the process of creating the most accurate list possible of all medications a client is taking and comparing that list against the physician’s orders at every transition of care. A client who is transferred to a step-down unit is at risk of medication errors due to changes in the level of care and the prescribing providers. Therefore, medication reconciliation should be performed for this client to prevent adverse drug events.

Choice A is wrong because a referral for social services does not involve a change in the client’s medications or care setting.

Choice B is wrong because transport to radiology is a temporary and short-term movement that does not require medication reconciliation.

Choice D is wrong because a consultation for physical therapy does not affect the client’s medication regimen or orders.

A. Calcium gluconate. B. Acetylcysteine. C. Flumazenil. D. Protamine sulfate.

Correct Answer is A

Explanation

Calcium gluconate is used to treat hypermagnesemia because it can help calm some symptoms such as impaired breathing, irregular heartbeat, and hypotension. Calcium also helps normalize the neuromuscular function that is affected by excess magnesium.

Choice B. Acetylcysteine is wrong because it is used to treat acetaminophen overdose and prevent kidney damage from contrast dye.

It has no role in treating hypermagnesemia.

Choice C. Flumazenil is wrong because it is used to reverse the effects of benzodiazepines, a class of sedative drugs.

It has no role in treating hypermagnesemia.

Choice D. Protamine sulfate is wrong because it is used to reverse the effects of heparin, an anticoagulant drug.

It has no role in treating hypermagnesemia.

Normal ranges for magnesium are 1.7 to 2.3 mg/dL or 0.7 to 1.1 mmol/L. Hypermagnesemia is defined as a magnesium level above 2.6 mg/dL or 1.5 mmol/L.

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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 teaching a newly licensed nurse about medication reconciliation. The nurse should instruct the newly licensed nurse to perform medication reconciliation for which of the following clients?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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