A nurse is caring for a client who is receiving heparin by continuous IV infusion for treatment of venous thrombosis. Which of the following laboratory values should the nurse monitor for in order to titrate the heparin dose?
Platelet function assay
aPTT
INR
Amylase
The Correct Answer is B
When caring for a client receiving heparin by continuous IV infusion for the treatment of venous thrombosis, the nurse should monitor the client's aPTT (Activated Partial Thromboplastin Time) to titrate the heparin dose.
Heparin is an anticoagulant medication used to prevent and treat blood clots. The aPTT is a coagulation test that measures the time it takes for the blood to clot when a specific activator is added. Monitoring the aPTT is a standard method for assessing the anticoagulant effect of heparin and ensuring that the client's blood remains within the desired therapeutic range.
The therapeutic range for aPTT while on heparin therapy varies depending on the indication and the client's condition but is generally maintained at a level that prolongs the clotting time enough to prevent and treat thrombosis while avoiding excessive bleeding risk.
Let's go through the other options:
A. Platelet function assay: While monitoring platelet function is essential for assessing overall hemostasis and platelet function, it is not specifically used for titrating heparin doses. Platelet function assays are more commonly used to assess the function of platelets in the context of platelet disorders or antiplatelet medication therapy.
C. INR (International Normalized Ratio): The INR is used to monitor the effect of vitamin K antagonist anticoagulants, such as warfarin, and is not the appropriate test for monitoring heparin therapy.
D. Amylase: Amylase is an enzyme produced by the pancreas and salivary glands and is not relevant for monitoring heparin therapy. Elevated amylase levels are typically associated with pancreatitis and not related to heparin treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should include in the teaching that hydrochlorothiazide therapy can elevate blood glucose levels in clients who have diabetes. Hydrochlorothiazide is a diuretic commonly used to treat hypertension (high blood pressure). While it is effective in reducing blood pressure, it can sometimes cause adverse effects on blood glucose levels, particularly in individuals with diabetes mellitus.
Hydrochlorothiazide can cause an increase in blood glucose levels by reducing insulin sensitivity, leading to potential hyperglycemia (high blood sugar) in some individuals. Clients with diabetes should closely monitor their blood glucose levels while taking hydrochlorothiazide and inform their healthcare provider if they notice significant changes.
Let's go through the other options:
A. "Blood glucose monitoring is likely to be inaccurate while taking hydrochlorothiazide": This statement is not accurate. Hydrochlorothiazide does not directly affect the accuracy of blood glucose monitoring. However, it is essential for clients with diabetes to be aware of the potential impact of hydrochlorothiazide on their blood glucose levels.
B. "You might need to decrease your insulin dosage while taking hydrochlorothiazide": Hydrochlorothiazide can potentially elevate blood glucose levels, which may require adjustments in diabetes management, including insulin dosage. However, it is not accurate to state that all clients will need to decrease their insulin dosage while taking hydrochlorothiazide. Each client's response to the medication may vary, and adjustments to diabetes medications should be made under the guidance of their healthcare provider based on individual blood glucose monitoring.
D. "Reducing sodium in your diet can help control your blood glucose while taking hydrochlorothiazide": While reducing sodium in the diet is generally a beneficial recommendation for individuals with hypertension, it is not directly related to controlling blood glucose levels in clients with diabetes. The primary focus for individuals with diabetes taking hydrochlorothiazide should be on monitoring blood glucose levels and working with their healthcare provider to manage any changes related to the medication.
Correct Answer is C
Explanation
The nurse should expect angioedema as one of the manifestations of anaphylaxis in a client experiencing an allergic reaction to an antibiotic. Angioedema is a severe swelling that occurs beneath the skin, typically affecting the face, lips, tongue, throat, or other body parts. It is a result of the release of histamine and other inflammatory mediators in response to the allergen.
Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and affect multiple body systems. In addition to angioedema, other common manifestations of anaphylaxis include:
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Difficulty breathing or wheezing due to bronchospasm
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Hives or urticaria, which are itchy raised skin rashes
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Severe itching or tingling sensation
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Rapid and weak pulse
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Low blood pressure leading to hypotension
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Nausea, vomiting, or diarrhea
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Feeling of impending doom or anxiety
Let's go through the other options:
A. Hypertonic reflexes: This is not a manifestation of anaphylaxis. "Hypertonic reflexes" are not typically associated with allergic reactions or anaphylaxis. Hypertonic reflexes refer to increased muscle tone, but they are not part of the usual presentation of anaphylaxis.
B. Increase in systolic blood pressure: Anaphylaxis usually leads to a decrease in blood pressure rather than an increase. The decrease in blood pressure can be severe and result in shock, which is a life-threatening condition.
D. Urinary retention: Urinary retention is not a common manifestation of anaphylaxis. Anaphylaxis primarily affects the respiratory and circulatory systems, leading to airway constriction, difficulty breathing, and cardiovascular collapse. Urinary retention is not directly related to the pathophysiology of anaphylaxis.
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