A nurse is caring for a client who has a pulmonary embolism and is receiving therapy with unfractionated heparin. Which of the following laboratory results indicates that the therapy is effective?

PT 12 seconds.

aPTT 75 seconds.

INR 1.1.

Platelets 200,000/mm².

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A PT (Prothrombin Time) of 12 seconds is not indicative of the effectiveness of heparin therapy for a pulmonary embolism. PT measures the extrinsic pathway of the coagulation cascade, and it is more relevant to monitor in patients on warfarin therapy.

Choice B rationale:

The aPTT (Activated Partial Thromboplastin Time) of 75 seconds is the correct choice as it reflects the effectiveness of unfractionated heparin therapy. Heparin works by inhibiting clotting factors in the intrinsic pathway, and the aPTT is used to monitor heparin's anticoagulant effect. The normal range for aPTT is typically 25-35 seconds.

Choice C rationale:

An INR (International Normalized Ratio) of 1.1 is not the appropriate parameter to assess the effectiveness of heparin therapy. INR is primarily used to monitor the effectiveness of oral anticoagulants like warfarin, not heparin.

Choice D rationale:

The platelet count of 200,000/mm² is not a suitable parameter to evaluate the effectiveness of heparin therapy. Platelet count is important for assessing the risk of bleeding or clotting disorders but does not directly measure the impact of heparin on clotting factors.

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Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

A. Place the client on droplet precautions. B. Perform a cranial nerve assessment on the client every 2 hr. C. Assist the client out of bed three times per day. D. Assess the client's weight daily.

Correct Answer is B

Explanation

Choice A rationale:
Placing the client on droplet precautions is appropriate for bacterial meningitis, as it is spread through respiratory droplets. This measure helps prevent the spread of infection to others.
Choice B rationale:
The nurse should clarify the prescription to perform a cranial nerve assessment every 2 hours. While cranial nerve assessment is crucial in monitoring neurological status, performing it every 2 hours is excessive and not supported by evidence-based practice. Frequent assessments can be uncomfortable for the client and may not provide additional meaningful information within such a short interval.
Choice C rationale:
Assisting the client out of bed three times per day is essential for promoting mobility and preventing complications such as pressure ulcers and muscle weakness. This prescription is appropriate and does not require clarification.
Choice D rationale:
Assessing the client's weight daily is essential in monitoring fluid balance and nutritional status. There is no need to clarify this prescription, as it is a standard practice in caring for clients with bacterial meningitis.

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A nurse is caring for a client who has a pulmonary embolism and is receiving therapy with unfractionated heparin. Which of the following laboratory results indicates that the therapy is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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