A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following actions should the nurse take?
Withhold the next dose of warfarin
Withhold the heparin infusion
Prepare to administer vitamin K
Prepare to administer alteplase
The Correct Answer is B
A. Withholding the next dose of warfarin is incorrect. Warfarin takes several days to reach therapeutic levels, and the INR of 1.8 is below the target range (typically 2.0–3.0 for PE treatment). Stopping warfarin is unnecessary.
B. Withholding the heparin infusion is correct. The aPTT is significantly elevated at 98 seconds (therapeutic range: 60–80 seconds for PE treatment), increasing the risk of bleeding. The nurse should pause the heparin infusion and notify the provider for dose adjustment.
C. Preparing to administer vitamin K is incorrect. Vitamin K reverses warfarin effects, but the INR of 1.8 is not dangerously high and does not require reversal.
D. Preparing to administer alteplase is incorrect. Alteplase (a thrombolytic) is used for massive PE with hemodynamic instability, not for a patient already receiving anticoagulation therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypotension is not a common adverse effect of estradiol; instead, it may cause hypertension.
B. Bruising can indicate thrombocytopenia or other clotting issues, which are serious adverse effects of estradiol and should be reported immediately.
C. Headaches are a common side effect of estradiol but are usually not severe; they typically do not require reporting unless they are persistent or severe.
D. Oliguria is not a known adverse effect of estradiol and may indicate other underlying issues that are unrelated to this medication.
Correct Answer is A
Explanation
A. Elevating the affected leg is an important intervention for reducing swelling and promoting venous return, which can help alleviate discomfort and prevent further complications.
B. Placing cold compresses on the edematous area may provide temporary relief but is not a standard intervention for deep-vein thrombosis and could potentially harm tissue if applied for too long.
C. Restricting the client to 1 L of fluid per day is inappropriate, as adequate hydration is essential for maintaining good venous health and preventing further complications.
D. Maintaining the client on bed rest is not necessary; while rest is important, early ambulation is encouraged to promote circulation and prevent further clot formation unless contraindicated.
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