Before the latest PT/INR results are back, the physician orders a heparin bolus of 5000 units
IV followed by an infusion of 1200 units/hr. The laboratory calls with a critical value—the
aPTT is 120 seconds.
Based on this result, what action will you take?
What will be an ideal response?
• The physician should be notified, and the infusion should be stopped or reduced and a follow-up
aPTT performed. The aPTT should be 1.5 to 2.5 times the control value.
• Monitor M.M. for signs of bleeding. Send a stool sample to the laboratory for testing for occult
blood.
• Monitor closely for developing disseminated intravascular coagulation (DIC) because this
complication is a possibility.
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The nurse caring for the terminally ill client and the family collects data about loss and grieving during the admission interview. Information important to collect includes: Standard Text: Select all that apply
1. Previous losses 2. Awareness of approaching loss 3. How grief was handled previously 4. Medications being taken for coping 5. History of alcohol abuse
Application of which of these medications on a burn wound can prevent the drying of the wound?
a. povidone-iodine (Betadine) c. gentamicin (Garamycin) b. bacitracin (Baci-guent) d. neomycin (Myci-guent)
The nurse performed a cover-uncover test on a client to test for atropia. When the left eye was covered, the right eye moved inward. The finding indicated that the client had:
1. Exotropia. 2. Esotropia. 3. No strabismus. 4. Vertical phoria.
A patient is readmitted to the hospital 3 days after having been discharged. She presents with the same respiratory symptoms she presented with on her first admission. She is assigned to the same nurse
The first thing that nurse should do is 1. A comprehensive health assessment, because as much information as possible is needed about why the patient has returned to the hospital. 2. A focused assessment of her respiratory system, because that is the system with the recurring problem. 3. An initial head-to-toe shift assessment to establish a baseline for future assessments. 4. Any form of assessment, because the nurse already has plenty of recent assessments from the patient's previous hospital stay to use as baselines.