a nurse is reviewing the laboratory values for a client who is receiving a continuous iv heparin infusion and has an aptt of 90 seconds which of the f
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PN ATI Capstone Proctored Comprehensive Assessment 2020 A

1. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?

Correct answer: B

Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.

2. A nurse is planning to administer epoetin alfa to a client who has chronic kidney failure. Which of the following data should the nurse plan to review prior to administration of this medication?

Correct answer: A

Rationale: The correct answer is A: Blood pressure. Epoetin alfa can increase blood pressure, especially in clients with chronic kidney failure. Monitoring blood pressure before administration is crucial to prevent hypertension. Reviewing temperature, blood glucose levels, or total protein levels is not directly related to the potential side effect of increased blood pressure associated with epoetin alfa.

3. A client with peptic ulcer disease reports a headache. Which of the following medications should the nurse plan to administer?

Correct answer: D

Rationale: Acetaminophen is the preferred analgesic for clients with peptic ulcer disease because it does not cause gastrointestinal irritation, unlike Ibuprofen, Naproxen, and Aspirin, which can exacerbate peptic ulcer symptoms and lead to gastrointestinal complications.

4. A nurse is caring for a client who has a new prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?

Correct answer: C

Rationale: The correct answer is C: Hypotension. Enalapril, an ACE inhibitor, can lead to hypotension, especially after the first dose. Choices A, B, and D are incorrect because enalapril is not typically associated with ecchymosis, jaundice, or hypokalemia as common adverse effects. Therefore, the nurse should primarily monitor the client for signs of hypotension.

5. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following indicates she is dehydrated?

Correct answer: A

Rationale: A urine specific gravity greater than 1.030 indicates dehydration. In this case, a urine specific gravity of 1.035 suggests concentrated urine, indicating dehydration. Choices B, C, and D have values that are not within the normal range for urine specific gravity and do not indicate dehydration. A urine specific gravity of 444, 2000, or 1111.1 are not physiologically possible values and are therefore incorrect.

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