Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer a heparin infusion of 25,000 units in 250 mL of normal saline at a rate of 1000 units per hour for a client diagnosed with a Deep Vein Thrombosis (DVT). The client’s initial activated partial thromboplastin time (aPTT) value is 35 seconds.
Which laboratory result would indicate that the aPTT is at a therapeutic level?
A. 30 seconds
None
B. 45 seconds
None
C. 60 seconds
None
D. 75 seconds
Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.
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Full Explanation
Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.
Similar Questions
The nurse is providing care for a client diagnosed with post-thrombotic syndrome who has a venous stasis ulcer. Which instructions should be given prior to discharge? (Select all that apply)
A. Increase intake of proteins, take vitamin C and zinc
Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.
B. Use care when walking to avoid bumping your limb
Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.
C. Cleanse the ulcer with soap and water
Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.
D. Apply cortisone cream to decrease itching
Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.
E. Put on compression stockings before getting out of bed
Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.
Full Explanation
Choice A rationale
Proteins, vitamin C, and zinc are essential for wound healing. Proteins are the building blocks for body tissue, and zinc plays a role in protein synthesis. Vitamin C is needed for the formation of collagen, a protein used to make skin, scar tissue, and blood vessels.
Choice B rationale
Care should be taken when walking to avoid bumping the limb. Any trauma to the affected limb could potentially worsen the condition or delay healing.
Choice C rationale
Cleaning the ulcer with soap and water may not be the best option. Soap can be irritating to the skin and may delay healing. Instead, the ulcer should be cleaned as per healthcare provider’s instructions.
Choice D rationale
Cortisone cream is not typically used for venous stasis ulcers. It can thin the skin and delay healing.
Choice E rationale
Compression stockings are often recommended for patients with post-thrombotic syndrome. They can help reduce swelling and improve blood flow, which can promote healing of the venous stasis ulcer.
A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?
A. Have the client drink 4 oz. of orange juice
Step 1 is to understand that a blood glucose level of 50 mg/dL is considered hypoglycemic. Immediate treatment is necessary to raise the blood glucose level. Step 2 is to follow the 15-15 rule for treating hypoglycemia, which recommends consuming 15 grams of carbohydrates and then checking blood glucose levels after 15 minutes. Four ounces of orange juice contains about 15 grams of carbohydrates and can quickly raise blood glucose levels.
B. Give the client 3 tbsp.
C. of sugar dissolved in 4 oz. of grape juice to drink
D. Monitor the client closely until dinner arrives
Full Explanation
Step 1 is to understand that a blood glucose level of 50 mg/dL is considered hypoglycemic. Immediate treatment is necessary to raise the blood glucose level.
Step 2 is to follow the 15-15 rule for treating hypoglycemia, which recommends consuming 15 grams of carbohydrates and then checking blood glucose levels after 15 minutes. Four ounces of orange juice contains about 15 grams of carbohydrates and can quickly raise blood glucose levels.
The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days.
What nursing actions are appropriate when administering this medication? (Select all that apply)
A. Assess for Red Man Syndrome
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
B. Assess the client’s hearing
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
C. Obtain an arterial blood gas (ABG)
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
D. Infuse the drug over 1-2 hours
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
E. Obtain an ordered trough level prior to next scheduled dose
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.
Full Explanation
Choice A rationale
Assess for Red Man Syndrome. Vancomycin can cause a reaction known as Red Man Syndrome, which is characterized by flushing and/or an erythematous rash that affects the face, neck, and upper torso. This is not an allergic reaction, but rather a direct histamine-release effect of the drug.
Choice B rationale
Assess the client’s hearing. Ototoxicity, which can manifest as hearing loss, is a potential side effect of vancomycin. Therefore, it’s important to monitor the client’s hearing during treatment.
Choice C rationale
Obtain an arterial blood gas (ABG). This is not typically required when administering vancomycin. ABGs are usually drawn to assess a patient’s acid-base balance and oxygenation status, not as a routine part of vancomycin administration.
Choice D rationale
Infuse the drug over 1-2 hours. Vancomycin should be administered over at least 60 minutes to avoid skin irritation. Infusing the drug too quickly can also increase the risk of Red Man Syndrome.
Choice E rationale
Obtain an ordered trough level prior to next scheduled dose. Monitoring vancomycin trough levels is important to ensure therapeutic efficacy and to avoid toxicity. Trough levels are typically drawn just before the next dose is due.