A nurse is reviewing a client's 0800 laboratory values at 1100. The nurse notes that the client received heparin at 1000. Which of the following laboratory values warrants an incident report?
INR 1.6
WBC 6,000/mm3
Hgb 16 g/dL
aPTT 90 seconds
The Correct Answer is D
Choice A rationale:
An INR of 1.6 is slightly elevated but does not necessarily warrant an incident report.
Choice B rationale:
A WBC count of 6,000/mm3 is within a normal range and would not warrant an incident report.
Choice C rationale:
A hemoglobin level of 16 g/dL is within a normal range and does not warrant an incident report.
Choice D rationale:
An aPTT of 90 seconds is significantly prolonged and may indicate excessive anticoagulation from the heparin administration. This could potentially be a safety concern and would warrant an incident report for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Nicotine nasal spray delivers a rapid dose of nicotine to the bloodstream, which can help reduce cravings and withdrawal symptoms. The recommended dose is 1 to 2 sprays in each nostril every hour, up to 40 sprays per day. The client should not sniff, swallow, or inhale while spraying, and should avoid contact with the eyes and skin.
Choice B rationale:
The nicotine patch should be changed every 24 hours, not every other day. The patch provides a steady dose of nicotine through the skin, which can help prevent cravings and withdrawal symptoms. The client should apply the patch to a clean, dry, and hairless area of the skin, and rotate the site of application daily.
Choice C rationale:
the nicotine gum should be chewed for about 30 minutes, not 10 minutes, before spitting it out. The gum releases nicotine into the mouth, which is then absorbed into the bloodstream through the mucous membranes. The client should chew the gum slowly until a peppery taste or tingling sensation occurs, then park it between the cheek and gum until the taste or sensation fades, then repeat the process.
Choice D rationale:
The client should avoid drinking beverages for 15 minutes before and during sucking on a nicotine lozenge, not just while sucking on it. The lozenge dissolves in the mouth and releases nicotine, which is then absorbed into the bloodstream through the mucous membranes. Drinking beverages can interfere with the absorption of nicotine and reduce the effectiveness of the lozenge.
Correct Answer is B
Explanation
Choice A rationale:
Morphine tablet is not likely to provide rapid relief within 1 hour for moderate to severe pain.
Choice B rationale:
Fentanyl transmucosa, such as a fentanyl lozenge or transmucosal patch, is a strong opioid analgesic that can provide rapid relief for breakthrough pain.
Choice C rationale:
A lidocaine patch is typically used for localized pain relief and might not provide the desired level of relief for systemic pain.
Choice D rationale:
Naloxone IV is an opioid antagonist used to reverse opioid overdose. It would not be appropriate to administer naloxone in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.