**What are some important nursing considerations for this medication? *.**

Protamine sulfate should be given slowly intravenously within 30 minutes of heparin administration.

Protamine sulfate should be given rapidly intramuscularly within 60 minutes of heparin administration.

Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration.

Protamine sulfate should be given rapidly intramuscularly within 30 minutes of heparin administration.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions. Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B. Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

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

Explanation

Choice A rationale:

Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.

Choice B rationale:

Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.

Choice C rationale:

Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.

Choice D rationale:

Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.

Choice E rationale:

Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.

A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

Correct Answer is B

Explanation

Choice A rationale:

Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.

Choice B rationale:

Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.

Choice C rationale:

Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.

Choice D rationale:

Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.

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What are some important nursing considerations for this medication? *.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

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

Explanation

Which is the best approach for the nurse to use when interviewing a client about intimate partner violence?

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

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**What are some important nursing considerations for this medication? *.**