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 A
Explanation
Choice A rationale:
Testicular cancer may present as a painless lump or swelling in the testicle. It's important for the client to monitor for any new or unusual lumps, as they could be indicative of cancer.
Choice B rationale:
A decreased size of the testicle is not a typical manifestation of testicular cancer. It is more commonly associated with conditions like testicular atrophy due to other causes.
Choice C rationale:
Asymmetry in the position of the testicles, with one testicle descending lower than the other, is a normal variation and not a sign of testicular cancer.
Choice D rationale:
Dilated veins above the testicle can be a sign of a varicocele, which is a separate condition from testicular cancer. It is caused by abnormal enlargement of veins in the scrotum and is generally not associated with cancer.
Correct Answer is B
Explanation
Choice A rationale:
Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.
Choice B rationale:
Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.
Choice C rationale:
Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.
Choice D rationale:
Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.
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