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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 nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first?
- A. Notify the health-care provider to have chest tubes reinserted STAT.
- B. Instruct the client to take slow shallow breaths until the tube is reinserted.
- C. Take no action and assess the client's respiratory status every 15 minutes.
- D. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.
Correct Answer: D
Rationale: An occlusive dressing taped on three sides (D) prevents air entry while allowing air exit, a priority. Notification (A), shallow breaths (B), and monitoring (C) follow.
If the client is typical of most others diagnosed with lung cancer, which early-warning sign was most likely ignored?
- A. Difficulty swallowing
- B. Gradual weight loss
- C. Persistent cough
- D. Coughing up blood
Correct Answer: C
Rationale: A persistent cough is a common early symptom of lung cancer that is often ignored, delaying diagnosis.
Where did the client's embolism most likely originate?
- A. The deep veins of the legs
- B. The pulmonary artery
- C. The superior vena cava
- D. The carotid artery
Correct Answer: A
Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
When caring for a client with influenza, the nurse would expect to assess for which signs and symptoms of hypoxia? Select all that apply.
- A. Cough
- B. Restlessness
- C. Fever
- D. Tachypnea
- E. Use of accessory muscles to breathe
- F. Cyanosis
Correct Answer: B, D, E, F
Rationale: Hypoxia manifests as restlessness, tachypnea, use of accessory muscles, and cyanosis due to inadequate oxygen delivery to tissues.