A nurse is caring for a client who has fractured ribs, has developed thrombophlebitis, and is being treated with a heparin drip. The client develops hematuria and has an activated partial thromboplastin time (aPTT) of 100 seconds (60 to 80 seconds). Which of the following actions should the nurse take first?
Turn off the heparin drip
Administer protamine sulfate
Repeat the aPTT now and in 1 hr
Obtain a portable chest x-ray
The Correct Answer is A
A. Turn off the heparin drip: The client’s aPTT is significantly elevated and is accompanied by active bleeding, indicated by hematuria. Stopping the heparin infusion is the most immediate action because it removes the source of ongoing anticoagulation and helps prevent further bleeding. This stabilizes the situation before additional corrective measures are taken.
B. Administer protamine sulfate: Protamine sulfate is the reversal agent for heparin and may be required, but it should be given after the heparin infusion is stopped. Administering it without stopping the drip allows continued anticoagulation, reducing the effectiveness of the reversal. The reversal medication is a secondary intervention.
C. Repeat the aPTT now and in 1 hr: Rechecking coagulation labs is appropriate to monitor progress, but it does not address the immediate risk of ongoing bleeding. Delaying action while repeating labs can allow further anticoagulation and worsening hemorrhagic symptoms. Lab monitoring becomes relevant only after the heparin drip is stopped.
D. Obtain a portable chest x-ray: A chest x-ray would not address the current problem of excessive anticoagulation and active bleeding. There is no indication of a thoracic complication requiring imaging at this moment, and performing this step would delay urgent action. The priority is to stop the heparin and control bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatotoxicity: Vancomycin is not commonly associated with liver toxicity. While liver function may be monitored in clients receiving multiple medications, hepatotoxicity is not a primary concern with vancomycin therapy.
B. Ototoxicity: Vancomycin can cause ototoxicity, particularly with high doses or prolonged therapy. This adverse effect may present as tinnitus or hearing loss, making it important for the nurse to monitor the client’s auditory function during treatment.
C. Hypercalcemia: Vancomycin does not affect calcium metabolism, so hypercalcemia is not an expected adverse reaction. Monitoring calcium levels is not routinely necessary for vancomycin administration.
D. Hypertension: Hypertension is not a known adverse effect of vancomycin. Blood pressure monitoring is standard for overall care, but vancomycin itself does not typically cause elevations in blood pressure.
Correct Answer is C
Explanation
A. Varenicline: Varenicline is used to aid smoking cessation by reducing cravings and withdrawal symptoms. It does not have efficacy in treating gambling disorder and is not indicated for behavioral addictions.
B. Disulfiram: Disulfiram is prescribed for alcohol use disorder to discourage alcohol consumption by causing unpleasant reactions when alcohol is ingested. It does not address the underlying behavioral or psychological aspects of gambling disorder.
C. Sertraline: Sertraline, a selective serotonin reuptake inhibitor (SSRI), can help reduce compulsive behaviors, impulsivity, and anxiety associated with gambling disorder. It may be used as part of a comprehensive treatment plan alongside therapy and behavioral interventions.
D. Clonidine: Clonidine is primarily used to treat hypertension, ADHD, and certain withdrawal symptoms. It does not target the compulsive behaviors or psychological aspects of gambling disorder and is not indicated for this purpose.
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