The nurse is caring for a postpartum client with a diagnosis of deep vein thrombosis who is receiving a continuous intravenous infusion of heparin sodium. Review of which laboratory result is the most important by the nurse?
1. Platelet count
2. Prothrombin time (PT)
3. International normalized ratio (INR)
4. Activated partial thromboplastin time (aPTT)
Answer: 4. Activated partial thromboplastin time (aPTT)
Explanation: Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. The aPTT time should be monitored, and the heparin sodium dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control value in seconds. The platelet count cannot be used to determine an adequate dosage for the heparin sodium infusion. The PT and the INR are used to monitor coagulation time when warfarin sodium is used.
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When teaching a local community about ways to conserve energy, which of the following would the community health nurse suggest?
A) Set the thermostat in the house to 68 degrees during the summer B) Open the blinds for sunlight during summer afternoon hours C) Replace any worn or lost insulation in the home D) Remove caulking from any broken windows or doors
A patient with a history of incontinence will undergo urodynamic testing in the physician's office. Because voiding in the presence of others can cause situational anxiety, the nurse should perform what action?
A) Administer diuretics as ordered. B) Push fluids for several hours prior to the test. C) Discuss possible test results as the patient voids. D) Help the patient to relax before and during the test.
Home care for a woman with a low-risk pregnancy should include:
A. encouragement to stay on bed rest. B. assessment of blood glucose. C. instruction on use of a uterine activity monitor. D. assessment of fetal heart rate and activity.
The nurse is providing care to a Navajo American adolescent patient who states, "I am an adult now in my culture." Which has occurred for the patient to make this statement?
1) Graduating from high school 2) Becoming engaged 3) Starting menstruation 4) Passing a driver's permit exam