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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.
Choice B rationale:
A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.
Choice C rationale:
A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.
Choice D rationale:
Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.
Correct Answer is C
Explanation
Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.
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