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 D
Explanation
Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
Correct Answer is B
Explanation
A. Triglycerides within the normal range do not indicate a need for additional nutrients.
B. A low albumin level of 2.8 g/dL indicates poor protein status and may suggest that the client requires additional protein in their enteral feeding to help with healing and overall nutrition.
C. A creatinine level of 1.1 mg/dL is within normal limits and does not indicate a need for additional nutrients.
D. Alkaline phosphatase at 118 units/L is within the normal range and does not suggest a deficiency requiring additional nutrients.
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