The oncoming nurse sees that the patient is receiving IV heparin at 7 mL/hr. The concentration of the heparin is 50,000 units in 250 ml of saline. The patient is ordered 1600 units of heparin per hour. The lab calls the oncoming nurse with the result of the patient's activated partial prothrombin time (aPTT) is 37 seconds. What actions will the oncoming nurse take? (SELECT ALL THAT APPLY)

notify the prescriber about the current dose of heparin the patient is receiving

ask the nurse leaving to place a second IV & anticipate an order for IV 0.9 saline

assess the patient's site for manifestations of infiltration

read the pt's lab result back to the lab technician confirming the pt's name & date of birth

notify the prescriber & anticipate an order to give protamine sulfate

Answer and Explanation

Correct Answer : A,C

A.   The nurse should notify the prescriber about the current dose (7 mL/hr) because the patient is ordered 1600 units of heparin per hour. The current infusion rate needs to be assessed in relation to the aPTT result, especially if the aPTT indicates that the patient may be at risk for bleeding.
B.   While having a second IV may be useful for administering fluids or medications in case of a bleeding emergency, there is no immediate indication for IV 0.9 saline in this scenario. The priority is to assess the heparin dosage and aPTT before making additional IV arrangements.
C.   It’s important to assess the IV site for signs of infiltration, especially since the patient is on heparin therapy. Infiltration can affect the effectiveness of the medication and cause complications, so this assessment is vital.
D.   While it is important to verify lab results, the nurse should primarily focus on addressing the current situation regarding the heparin infusion and the patient’s anticoagulation status rather than confirming lab results with the lab technician at this moment.
E.   While protamine sulfate is an antidote to heparin, it is not warranted based solely on the aPTT result of 37 seconds. The normal aPTT range is typically around 30-40 seconds, depending on the laboratory standards, and the aPTT may not indicate that the patient requires reversal of heparin at this time.

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Correct Answer is D

Explanation

A. While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B. While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C. Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D. Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

A. Continue walking to the point of pain B. Do not walk if a leg ulcer develops C. Elevate the feet for 30 minutes after walking D. Avoid exercise that places the feet in a dependent position

Correct Answer is A

Explanation

A. Clients with PAD often experience claudication (pain in the legs due to inadequate blood flow) during exercise. They should be encouraged to walk to the point of pain, then rest until the pain subsides, and then continue walking. This approach can improve circulation over time.
B. While it’s crucial to monitor leg ulcers, exercise can still be beneficial unless advised otherwise by a healthcare provider. Walking can promote circulation, which is important for healing. However, if a leg ulcer is present, the client should consult their healthcare provider about appropriate activity levels.
C. While elevating the feet can help reduce swelling, it's generally more beneficial for clients with PAD to keep their legs in a dependent position after walking. This position encourages blood flow to the legs, which can help alleviate symptoms and improve circulation.
D. Exercise that encourages movement and maintains blood flow to the legs is important for those with PAD. While certain positions may exacerbate symptoms, exercises like walking should be encouraged. Keeping the feet in a dependent position can help with blood flow post-exercise.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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