A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

aPTT

INR

WBC count

Answer and Explanation

The Correct Answer is A

A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.

B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.

C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.

D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.

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Correct Answer is C

Explanation

A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.

B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.

C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.

D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.

A. The solution temperature should be determined by the client's comfort level. B. The temperature of the enema is unrelated to the enema's eﬀectiveness. C. The solution should approximate the client's body temperature (98°F or 36°C). D. The temperature should be higher (110°F or 43°C) than the client's body temperature.

Correct Answer is C

Explanation

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the

stool. It is usually oil-based and contains 90-120 ml of solution.

The temperature of the enema solution aﬀects the eﬀectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.

The ideal temperature for an enema solution is close to the client's body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions .

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A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin?

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Naxlex Comprehensive Predictor Exams

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Explanation

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