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A patient is ordered to start an IV continuous Heparin drip. Prior to starting the medication, the nurse would ensure what information is gathered correctly before initiating the drip? Select all that apply: *.

Vital signs

Weight

PT/INR level

EKG

aPTT level.

Answer and Explanation

Correct Answer : B,E

The nurse would need to know the patient’s weight and aPTT level before starting the IV continuous Heparin drip.

Here is why:

• Weight: Heparin dosing is based on the patient’s weight, so the nurse would want to make sure the documented weight of the patient is current and accurate. The initial bolus and infusion rate are calculated using the patient’s weight in kilograms.

• aPTT: Heparin works by enhancing the activation of antithrombin III, which prevents the activation of thrombin and the conversion of fibrinogen to fibrin. Heparin affects the intrinsic pathway of clotting, and its therapeutic effect is monitored by measuring the activated partial thromboplastin time (aPTT). The normal range for aPTT is about 30-40 seconds, and the therapeutic range for Heparin is 1.5-2.5 times the normal value. The nurse would need to check the baseline aPTT before starting the drip, and then collect an aPTT level every 6 hours per protocol to adjust the infusion rate as needed.

The other choices are wrong because:

• Vital signs: Although vital signs are important to monitor for any patient, they are not specific to Heparin therapy. Heparin does not affect blood pressure, heart rate, respiratory rate, or temperature directly.

• PT/INR: These are coagulation tests that measure the extrinsic pathway of clotting, which is affected by Vitamin K antagonists such as Warfarin. Heparin does not affect the PT/INR levels, so they are not relevant for Heparin therapy.

• EKG: An electrocardiogram (EKG) is a test that measures the electrical activity of the heart. It can help diagnose cardiac arrhythmias, ischemia, infarction, electrolyte imbalances, and other cardiac conditions.

Heparin does not affect the electrical conduction of the heart, so an EKG is not necessary before starting Heparin therapy

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Correct Answer is B

Explanation

This is because alteplase [Activase] is a thrombolytic drug that dissolves blood clots and can cause bleeding complications, especially intracranial hemorrhage.Neurologic assessment is essential to detect any signs of bleeding in the brain, such as altered level of consciousness, headache, or focal deficits.

Choice A is wrong because applying pressure to needleless access sites after giving medications is a standard precaution to prevent bleeding and infection.It is not specific to alteplase [Activase] therapy.

Choice C is wrong because administering heparin when partial thromboplastin time (PTT) is less than 70 seconds is not recommended for patients who have received alteplase [Activase].

Heparin is an anticoagulant that can increase the risk of bleeding and should be used with caution in patients who have received thrombolytic therapy.The PTT should be monitored closely and heparin should be withheld if the PTT is above the therapeutic range.

Choice D is wrong because giving aspirin when platelet count is greater than 150,000/mm3 is not indicated for patients who have received alteplase [Activase].

Aspirin is an antiplatelet drug that can also increase the risk of bleeding and should be avoided in patients who have received thrombolytic therapy.

The platelet count should be monitored closely and aspirin should be withheld if the platelet count is below the normal range (150,000 to 450,000/mm3).

A. “I will take aspirin if I get a headache.” B. “I will avoid activities that may cause injury.” C. “I will take my medication with food.” D. “I will stop taking my medication if I feel better.”.

Correct Answer is B

Explanation

This statement indicates that the patient understands that rivaroxaban (Xarelto) is an anticoagulant that can increase the risk of bleeding and bruising.The patient should avoid activities that may cause injury, such as contact sports, sharp objects, or falls.

Choice A is wrong because aspirin is also an antiplatelet drug that can further increase the risk of bleeding when taken with rivaroxaban.The patient should not take aspirin or any other nonsteroidal anti-inflammatory drugs (NSAIDs) without consulting the prescriber.

Choice C is wrong because rivaroxaban can be taken with or without food.The patient does not need to take the medication with food to prevent stomach upset or absorption problems.

Choice D is wrong because rivaroxaban should be taken as prescribed and not stopped abruptly without consulting the prescriber.Stopping the medication can increase the risk of blood clots and stroke.The patient should not stop taking the medication even if they feel better or have no symptoms.

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A patient is ordered to start an IV continuous Heparin drip. Prior to starting the medication, the nurse would ensure what information is gathered correctly before initiating the drip? Select all that apply: *.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has received alteplase [Activase]. It is most important for the nurse to take which action?

Correct Answer is B

Explanation

A patient has been prescribed rivaroxaban (Xarelto) for deep vein thrombosis (DVT). Which statement by the patient indicates understanding of medication teaching?

Correct Answer is B

Explanation

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