A nurse is preparing to administer a heparin infusion of 25,000 units in 250 mL of normal saline at a rate of 1000 units per hour for a client diagnosed with a Deep Vein Thrombosis (DVT). The client’s initial activated partial thromboplastin time (aPTT) value is 35 seconds.

Which laboratory result would indicate that the aPTT is at a therapeutic level?

30 seconds

45 seconds

60 seconds

75 seconds

Answer and Explanation

The Correct Answer is D

Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.

Choice B rationale

Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.

Choice C rationale

Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.

Choice D rationale

Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.

Choice E rationale

Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.

A. Intermittent claudication B. Foot ulcers C. Pain at rest D. Dependent rubor

Correct Answer is A

Explanation

Choice A rationale

Intermittent claudication, which involves limb pain or cramping that generally begins when exercising and improves while resting, is a common symptom in the early stages of PAD5.

Choice B rationale

Foot ulcers are not typically a symptom of the early stages of PAD. They are more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

Choice C rationale

Pain at rest is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

Choice D rationale

Dependent rubor is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.

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Naxlex Comprehensive Predictor Exams

The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days. What nursing actions are appropriate when administering this medication? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

A nurse is caring for a patient who has peripheral arterial disease (PAD). What symptoms should the nurse expect to find in the early stage of the disease?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

The nurse identifies the problem of Fluid Volume Excess for a patient. Which assessment finding validates this problem?

A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

The nurse explains to a patient diagnosed with diabetes mellitus that the major benefit of frequent self-monitoring of blood glucose is that:

A nurse is educating a patient with diabetes mellitus about the chronic complications associated with the disease. What information should be included in the teaching?

The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes. What should be the nurse’s teaching priority?

The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

The nurse is caring for a client who is being evaluated for possible deep vein thrombosis of the right extremity. Which laboratory result is of most concern to the nurse?