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 D
Explanation
Choice A rationale:
Taking an HMG-CoA reductase inhibitor (statin) is not directly related to digoxin toxicity.
Choice B rationale:
Having a prolapsed mitral valve is not a known risk factor for digoxin toxicity.
Choice C rationale:
Having a history of COPD is not directly associated with digoxin toxicity.
Choice D rationale:
High-ceiling diuretics (loop diuretics) can lead to electrolyte imbalances, such as hypokalemia, which can increase the risk of digoxin toxicity. Potassium plays a role in the effects of digoxin on the heart, and low levels can potentiate toxicity.
Correct Answer is C
Explanation
Choice A rationale:
Amphotericin B lipid complex is normally yellow in color, so discarding it would be wasteful and inappropriate. The nurse should only discard the medication if it is cloudy, discolored, or contains particulate matter.
Choice B rationale:
Amphotericin B lipid complex should be administered over 1 hr, not 2 hr, to reduce the risk of infusion-related reactions such as fever, chills, rigors, hypotension, and tachycardia. The nurse should also premedicate the client with antipyretics, antihistamines, and corticosteroids to prevent or minimize these reactions.
Choice C rationale:
Priming the tubing with a compatible solution, such as 0.9% sodium chloride, helps prevent the medication from adhering to the tubing and ensures that the full dose reaches the client.
Choice D rationale:
Amphotericin B lipid complex should be administered using an infusion pump, not a gravity flow set, to ensure accurate and consistent delivery of the medication. The nurse should also use a filter needle when drawing up the medication from the vial and a 5-micron filter when infusing it to remove any impurities or aggregates.
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