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A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 80 seconds. The client's baseline before the initiation of therapy was 30 seconds. Which action does the nurse anticipate is needed?
- A. Shutting off the heparin infusion
- B. Increasing the rate of the heparin infusion
- C. Decreasing the rate of the heparin infusion
- D. Leaving the rate of the heparin infusion as is
Correct Answer: C
Rationale: The nurse needs to decrease the rate of the heparin infusion. The therapeutic dose of heparin for the treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. With the client's aPTT level elevated to 80 seconds from a baseline of 30 seconds, it indicates that the current rate of heparin infusion is too high. Lowering the rate of infusion is necessary to bring the aPTT within the desired therapeutic range. Choices A, B, and D are incorrect because shutting off the infusion, increasing the rate, or leaving it as is would not address the elevated aPTT level and may lead to complications.
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A client with polycystic kidney disease (PKD is being assessed by a nurse. Which assessment finding should prompt the nurse to immediately contact the healthcare provider?
- A. Flank pain
- B. Periorbital edema
- C. Bloody and cloudy urine
- D. Enlarged abdomen
Correct Answer: B
Rationale: Periorbital edema would not typically be associated with polycystic kidney disease (PKD) and could indicate other underlying issues that require immediate attention. Flank pain and an enlarged abdomen are common findings in PKD due to kidney enlargement and displacement of other organs. Bloody or cloudy urine can result from cyst rupture or infection, which are expected in PKD. Therefore, periorbital edema is the most alarming finding in this scenario and warrants prompt notification of the healthcare provider.
Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician's orders to ensure that the prescribed flow is not greater than:
- A. 1 L/min
- B. 3 L/min
- C. 4 L/min
- D. 6 L/min
Correct Answer: B
Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.
The patient weighs 75 kg and is receiving IV fluids at a rate of 50 mL/hour, having consumed 100 mL orally in the past 24 hours. What action will the nurse take?
- A. Contact the provider to ask about increasing the IV rate to 90 mL/hour.
- B. Discuss with the provider the need to increase the IV rate to 150 mL/hour.
- C. Encourage the patient to drink more water so the IV can be discontinued.
- D. Instruct the patient to drink 250 mL of water every 8 hours.
Correct Answer: A
Rationale: The recommended daily fluid intake for adults is 30 to 40 mL/kg/day. For a patient weighing 75 kg, the minimum intake should be 2250 mL/day. The patient is currently receiving 1200 mL IV and 100 mL orally, totaling 1300 mL. Increasing the IV rate to 90 mL/hour would provide a total of 2160 mL, which could meet the patient's needs if oral intake continues. Option B suggests increasing the IV rate to 150 mL/hour, resulting in an excessive fluid intake of 3600 mL/day, surpassing the recommended amount. Option C, encouraging increased fluid intake, is not recommended as the patient is already struggling with fluid intake. Option D, instructing the patient to drink 250 mL of water every 8 hours, would still fall short of the required fluid intake of 2250 mL/day.
A client is being prepared for a colonoscopy. Into which position does the nurse assist the client for the procedure?
- A. Left Sims' position
- B. Lithotomy position
- C. Knee-chest position
- D. Right Sims' position
Correct Answer: A
Rationale: During a colonoscopy, the client is positioned in the left Sims' position. This position is chosen as it optimally utilizes the client's anatomy to facilitate the introduction of the colonoscope. The lithotomy position (Choice B) is commonly used for gynecological exams, not colonoscopies. The knee-chest position (Choice C) is typically employed for rectal examinations or certain surgical procedures, not colonoscopies. The right Sims' position (Choice D) is a less common position for colonoscopy compared to the left Sims' position.
A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose determination in the morning. What does the nurse tell the client is acceptable to consume on the morning of the test?
- A. Water
- B. Tea without sugar
- C. Coffee without milk
- D. Clear liquids like apple juice
Correct Answer: A
Rationale: The correct answer is A: Water. A client scheduled for a fasting blood glucose test should only consume water after midnight to ensure accurate test results. Choosing options B, C, or D, which include tea, coffee, or clear liquids like apple juice, is incorrect as they may contain substances that can affect the blood glucose levels, leading to inaccurate test results.