Nokea
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.
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The client has had a total laryngectomy. Which referral is specific for this surgery?
- A. CanSurmount.
- B. Dialogue.
- C. Lost Chord Club.
- D. SmokEnders.
Correct Answer: C
Rationale: Lost Chord Club (C) supports laryngectomy patients with communication and adjustment. CanSurmount (A), Dialogue (B), and SmokEnders (D) are for cancer, CLL, and smoking cessation.
Which oxygen flow rate is most appropriate for the nurse to administer for this client?
- A. 2 L/minute
- B. 5 L/minute
- C. 8 L/minute
- D. 10 L/minute
Correct Answer: A
Rationale: A low flow rate of 2 L/minute is appropriate for COPD clients to avoid suppressing the hypoxic drive while improving oxygenation.
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
- A. A 55-year-old male with hyperlipidemia and diabetes.
- B. A 70-year-old female with severe sepsis.
- C. A 25-year-old male who uses intravenous drugs.
- D. A 65-year-old female who is post-op day 1 after joint replacement surgery.
Correct Answer: B,C,D
Rationale: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care?
- A. The client has no signs of respiratory distress.
- B. The client shows an improved respiratory pattern.
- C. The client demonstrates intolerance to activity.
- D. The client participates in establishing goals.
Correct Answer: C
Rationale: Activity intolerance (C) indicates poor COPD control, requiring plan revision. No distress (A), improved breathing (B), and goal participation (D) are positive outcomes.
When caring for a client with a flail chest, which nursing action is most appropriate?
- A. Suction the client's airway.
- B. Tape the chest securely.
- C. Apply a chest binder.
- D. Encourage coughing.
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.