A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?
INR 0.8, aPTT 85 seconds.
INR 2, aPTT 60 seconds.
The Correct Answer is B
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Prolonged sun exposure is a risk factor for osteoporosis because it can lead to vitamin D deficiency. Vitamin D is essential for calcium absorption, and low levels of vitamin D can contribute to reduced bone density and increased risk of fractures.
Choice B rationale:
Reduced intake of vitamin E is not a well-established risk factor for osteoporosis. Vitamin E is an antioxidant and plays a role in various bodily processes, but its association with osteoporosis is not supported by strong evidence.
Choice C rationale:
Drinking one glass of wine per day is not a risk factor for osteoporosis. In fact, moderate alcohol consumption has been suggested to have a protective effect on bone density in some studies.
Choice D rationale:
Exposure to second-hand tobacco smoke is a risk factor for osteoporosis. Smoking and exposure to tobacco smoke have been linked to decreased bone density and increased risk of fractures, making this an important point to include in the teaching.
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