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A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?
- A. Continue the heparin infusion as prescribed.
- B. Decrease the heparin infusion rate.
- C. Increase the heparin infusion rate.
- D. Stop the heparin infusion and notify the healthcare provider.
Correct Answer: D
Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.
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The healthcare professional is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the healthcare professional include?
- A. Wear the brace over a T-shirt for 23 hours a day.
- B. Remove the brace while sleeping.
- C. Wear the brace directly against the skin.
- D. Remove the brace while eating.
Correct Answer: A
Rationale: The correct answer is A. A Milwaukee brace should be worn over a T-shirt for 23 hours a day to reduce friction and chafing of the skin. This ensures that the brace is not directly against the skin, which can cause discomfort and skin irritation. Choice B is incorrect because the brace should typically be worn continuously, even while sleeping, unless otherwise instructed by a healthcare provider. Choice C is incorrect as wearing the brace directly against the skin can lead to skin issues. Choice D is incorrect since the brace should not be removed while eating to maintain the prescribed wear time.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
- A. Administer the dose as prescribed.
- B. Hold the medication.
- C. Call the healthcare provider.
- D. Repeat the vital signs in 30 minutes.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a follow-up home visit, the nurse observes that a client with chronic obstructive pulmonary disease (COPD) is using accessory muscles to breathe and has a pulse oximetry reading of 88%. What action should the nurse take first?
- A. Administer a prescribed bronchodilator
- B. Increase the oxygen flow rate
- C. Instruct the client to perform pursed-lip breathing
- D. Notify the healthcare provider immediately
Correct Answer: C
Rationale: In this situation, the nurse should first instruct the client to perform pursed-lip breathing. Pursed-lip breathing helps improve oxygenation and decrease the work of breathing in clients with COPD. Administering a bronchodilator or increasing the oxygen flow rate may be necessary interventions but addressing the breathing technique through pursed-lip breathing is the initial action to optimize oxygenation. Notifying the healthcare provider immediately is not the first action indicated in this scenario; the nurse should intervene promptly to assist the client in improving breathing before escalating the situation.
A client with chronic kidney disease is experiencing pruritus. Which intervention should the nurse include in the plan of care?
- A. Administer antihistamines as prescribed.
- B. Apply moisturizing lotion to the skin.
- C. Use cool water for bathing.
- D. Encourage a high-protein diet.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing to administer a scheduled dose of digoxin (Lanoxin) to a client. Which assessment finding should the nurse report to the healthcare provider?
- A. Heart rate of 90 beats per minute.
- B. Serum potassium level of 4.0 mEq/L.
- C. Blood pressure of 130/80 mm Hg.
- D. Client reports seeing halos around lights.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.