A nurse is caring for a patient who has a new prescription for warfarin.
Which of the following diagnostic test results should the nurse use to monitor the therapy’s effect?
Platelet count.
White blood cell count (WBC).
Prothrombin time (PT).
Activated partial thromboplastin time (aPTT).
The Correct Answer is C
Platelet count is not the primary diagnostic test used to monitor the therapy’s effect of warfarin. Platelets are involved in the clotting process, but warfarin specifically works by inhibiting the synthesis of vitamin K-dependent clotting factors, which does not directly involve platelets.
Choice B rationale
The white blood cell count (WBC) is not used to monitor the effect of warfarin therapy. WBC is typically used to monitor for infection or inflammation, not the coagulation status of a patient.
Choice C rationale
Prothrombin time (PT) is the correct answer. Warfarin therapy is monitored using the PT, which is reported as the International Normalized Ratio (INR). Warfarin inhibits the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and Proteins C and S. The PT/INR is sensitive to changes in these factors. An elevated INR indicates a higher risk of bleeding, while a lower INR suggests a higher risk of clotting.
Choice D rationale
Activated partial thromboplastin time (aPTT) is not typically used to monitor warfarin therapy. The aPTT test evaluates the intrinsic and common pathways of coagulation, which includes factors XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen). Warfarin affects the extrinsic pathway and common pathway, not the intrinsic pathway. Therefore, aPTT is not the best test to monitor the effects of warfarin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Irrigating the nasogastric tube with tap water is not recommended. Tap water is not sterile and can introduce bacteria into the stomach, potentially causing infection.
Choice B rationale
Marking abdominal girth once daily is not sufficient for a client who is postoperative following peritoneal lavage for peritonitis. This client is at risk for complications such as abscess formation and bowel obstruction, which can cause rapid changes in abdominal girth. Therefore, abdominal girth should be measured more frequently.
Choice C rationale
Placing the client in a high Fowler’s position is the correct intervention. This position, which involves the client sitting up at an angle of 45 to 60 degrees, can help reduce pressure on the abdominal area, promote better lung expansion, and facilitate drainage of gastric contents, thus reducing the risk of aspiration.
Choice D rationale
Ambulating the client twice daily is not appropriate in this case. The client has just undergone a major abdominal surgery and has a nasogastric tube and closed-suction drains in place. Early ambulation may not be feasible due to the risk of dislodging the drains or causing pain and discomfort.
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea.The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance.It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance.Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed.This step is critical to prevent complications from severe diarrhea.
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