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Medical Surgical 1 (Southeastern University)
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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
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Chapter 33: Management of Patients With Nonmalignant Hematologic
Disorders
1.
A nurse is caring for a patient who has sickle cell anemia and the nurses assessment reveals the
possibility of substance abuse. What is the nurses most appropriate action?
A)
Encourage the patient to rely on complementary and alternative therapies.
B)
Encourage the patient to seek care from a single provider for pain relief.
C)
Teach the patient to accept chronic pain as an inevitable aspect of the disease.
D)
Limit the reporting of emergency department visits to the primary health care provider.
Ans:
B
Feedback:
The patient should be encouraged to use a single primary health care provider to address health care
concerns. Emergency department visits should be reported to the primary health care provider to achieve
optimal management of the disease. It would inappropriate to teach the patient to simply accept his or
her pain. Complementary therapies are usually insufficient to fully address pain in sickle cell disease.
2.
A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission
assessment, the patient asks the nurse to explain the disease. What should the nurse explain to this
patient?
A)
There could be an attack on the platelets by antibodies.
B)
There could be decreased production of platelets.
C)
There could be impaired communication between platelets.
D)
There could be an autoimmune process causing platelet malfunction.
Ans:
B
Feedback:
Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or
increased consumption of platelets. Impaired platelet communication, antibodies, and autoimmune
processes are not typical pathologies.
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A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not
responding to conservative treatments, and his condition is now becoming life threatening. The nurse is
aware that a treatment option in this case may include what?
A)
Hepatectomy
B)
Vitamin K administration
C)
Platelet transfusion
D)
Splenectomy
Ans:
D
Feedback:
A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to
conservative treatment. Vitamin K administration is treatment for vitamin K deficiency and does not
resolve anemia. Platelet transfusion may be the course of treatment for some bleeding disorders.
Hepatectomy would not help the patient.
4.
A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron
supplements. What should the nurse include in health education?
A)
Take the iron with dairy products to enhance absorption.
B)
Increase the intake of vitamin E to enhance absorption.
C)
Iron will cause the stools to darken in color.
D)
Limit foods high in fiber due to the risk for diarrhea.
Ans:
C
Feedback:
The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be
taken on an empty stomach, as its absorption is affected by food, especially dairy products. Patients
should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber
should be consumed to minimize problems with constipation, a common side effect associated with iron
therapy.
5.
The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is
visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what
form of what hematologic disorder?
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A)
Sickle cell anemia
B)
Hemophilia
C)
Megaloblastic anemia
D)
Thrombocytopenia
Ans:
C
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Feedback:
A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease,
hemophilia, and thrombocytopenia do not have symptoms involving the tongue.
6.
A patient with renal failure has decreased erythropoietin production. Upon analysis of the patients
complete blood count, the nurse will expect which of the following results?
A)
An increased hemoglobin and decreased hematocrit
B)
A decreased hemoglobin and hematocrit
C)
A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW)
D)
An increased MCV and RDW
Ans:
B
Feedback:
The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The
patient will have normal MCV and RDW because the erythrocytes are normal in appearance.
7.
A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica.
Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse
suspect that the patient will be diagnosed?
A)
Iron deficiency anemia
B)
Pernicious anemia
C)
Sickle cell anemia
D)
Hemolytic anemia
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A
Feedback:
A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency
anemia. TIBC may also be elevated. None of the other anemias are associated with pica.
8.
A patient comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin
concentration and an increased reticulocyte count. What would the nurse suspect the patient has?
A)
A hypoproliferative anemia
B)
A leukemia
C)
Thrombocytopenia
D)
A hemolytic anemia
Ans:
D
Feedback:
In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from
the erythrocytes into the plasma; the released hemoglobin is converted in large part to bilirubin, and
therefore the bilirubin concentration rises. The increased erythrocyte destruction leads to tissue hypoxia,
which in turn stimulates erythropoietin production. This increased production is reflected in an increased
reticulocyte count as the bone marrow responds to the loss of erythrocytes. Hypoproliferative anemias,
leukemia, and thrombocytopenia lack this pathology and presentation.
9.
A nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness
and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue, the
workload on the heart is increased. What signs and symptoms might develop if this patient goes into
heart failure?
A)
Peripheral edema
B)
Nausea and vomiting
C)
Migraine
D)
Fever
Ans:
A
Feedback:
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Cardiac status should be carefully assessed in patients with anemia. When the hemoglobin level is low,
the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to
hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia,
palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually
develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral
edema. Nausea, migraine, and fever are not associated with heart failure.
10. A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer
which of the following medications?
A)
Folic acid
B)
Vitamin B12
C)
Lactulose
D)
Magnesium sulfate
Ans:
B
Feedback:
Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic
acid do not address the pathology of this type of anemia.
11. A patients blood work reveals a platelet level of 17,000/mm3. When inspecting the patients
integumentary system, what finding would be most consistent with this platelet level?
A)
Dermatitis
B)
Petechiae
C)
Urticaria
D)
Alopecia
Ans:
B
Feedback:
When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not
normally result in dermatitis, urticaria (hives), or alopecia (hair loss).
12. A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the
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admission assessment, the nurse must be alert for what medications that potentially alter platelet
function? Select all that apply.
A)
Antihypertensives
B)
Penicillins
C)
Sulfa-containing medications
D)
Aspirin-based drugs
E)
NSAIDs
Ans:
C, D, E
Feedback:
The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g.,
aspirin-based or other NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function.
13. A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from
a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is
ruled out. When assessing the patient, areas of ecchymosis are noted on other areas of the body. Which
of the following is the most plausible cause of the patients signs and symptoms?
A)
Lymphoma
B)
Leukemia
C)
Hemophilia
D)
Hepatic dysfunction
Ans:
D
Feedback:
Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic
dysfunction. The majority of hemophiliacs are diagnosed as children. The scenario does not describe
signs or symptoms of lymphoma or leukemia.
14. A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal
varices; an attempt to stop the bleeding has been only partially successful. What would the critical care
nurse expect the care team to order for this patient?
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A)
Packed red blood cells (PRBCs)
B)
Vitamin K
C)
Oral anticoagulants
D)
Heparin infusion
Ans:
A
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Feedback:
Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal
varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required.
Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the
bleeding of the varices. Anticoagulants would exacerbate the patients bleeding.
15. The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse
knows that a priority nursing diagnosis for a patient with hemophilia is what?
A)
Hypothermia
B)
Diarrhea
C)
Ineffective coping
D)
Imbalanced nutrition: Less than body requirements
Ans:
C
Feedback:
Most patients with hemophilia are diagnosed as children. They often require assistance in coping with
the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can
be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or
imbalanced nutrition.
16. A group of nurses are learning about the high incidence and prevalence of anemia among different
populations. Which of the following individuals is most likely to have anemia?
A)
A 50-year-old African-American woman who is going through menopause
B)
An 81-year-old woman who has chronic heart failure
C)
A 48-year-old man who travels extensively and has a high-stress job
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D)
A 13-year-old girl who has just experienced menarche
Ans:
B
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Feedback:
The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of
anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits
high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.
17. An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely
to apply to this patients health status?
A)
Risk for deficient fluid volume related to impaired erythropoiesis
B)
Risk for infection related to tissue hypoxia
C)
Acute pain related to uncontrolled hemolysis
D)
Fatigue related to decreased oxygen-carrying capacity
Ans:
D
Feedback:
Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally
result in acute pain or fluid deficit. The patient may have an increased risk of infection due to impaired
immune function, but fatigue is more likely.
18. A patient has been living with a diagnosis of anemia for several years and has experienced recent
declines in her hemoglobin levels despite active treatment. What assessment finding would signal
complications of anemia?
A)
Venous ulcers and visual disturbances
B)
Fever and signs of hyperkalemia
C)
Epistaxis and gastroesophageal reflux
D)
Ascites and peripheral edema
Ans:
D
Feedback:
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A significant complication of anemia is heart failure from chronic diminished blood volume and the
hearts compensatory effort to increase cardiac output. Patients with anemia should be assessed for signs
and symptoms of heart failure, including ascites and peripheral edema. None of the other listed signs and
symptoms is characteristic of heart failure.
19. A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of irondeficiency anemia in recent weeks. When providing the patient with nutritional guidelines and meal
suggestions, what foods would be most likely to increase the womans iron stores?
A)
Salmon accompanied by whole milk
B)
Mixed vegetables and brown rice
C)
Beef liver accompanied by orange juice
D)
Yogurt, almonds, and whole grain oats
Ans:
C
Feedback:
Food sources high in iron include organ meats, other meats, beans (e.g., black, pinto, and garbanzo),
leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g.,
orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange
juice are most likely to be of benefit.
20. A patient with poorly controlled diabetes has developed end-stage renal failure and consequent anemia.
When reviewing this patients treatment plan, the nurse should anticipate the use of what drug?
A)
Magnesium sulfate
B)
Epoetin alfa
C)
Low-molecular weight heparin
D)
Vitamin K
Ans:
B
Feedback:
The availability of recombinant erythropoietin (epoetin alfa [Epogen, Procrit], darbepoetin alfa
[Aranesp]) has dramatically altered the management of anemia in end-stage renal disease. Heparin,
vitamin K, and magnesium are not indicated in the treatment of renal failure or the consequent anemia.
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21. A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for
the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the
patients plan of care?
A)
Risk for disuse syndrome related to ineffective peripheral circulation
B)
Functional urinary incontinence related to urethral occlusion
C)
Ineffective tissue perfusion related to thrombosis
D)
Ineffective thermoregulation related to hypothalamic dysfunction
Ans:
C
Feedback:
There are multiple potential complications of sickle cell disease and sickle cell crises. Central among
these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are
not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse
syndrome is not associated with the effects of acute vaso-occlusive crisis.
22. A patient is being treated on the medical unit for a sickle cell crisis. The nurses most recent assessment
reveals an oral temperature of 100.5F and a new onset of fine crackles on lung auscultation. What is the
nurses most appropriate action?
A)
Apply supplementary oxygen by nasal cannula.
B)
Administer bronchodilators by nebulizer.
C)
Liaise with the respiratory therapist and consider high-flow oxygen.
D)
Inform the primary care provider that the patient may have an infection.
Ans:
D
Feedback:
Patients with sickle cell disease are highly susceptible to infection,thus any early signs of infection
should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and
bronchodilators are not indicated.
23. The medical nurse is aware that patients with sickle cell anemia benefit from understanding what
situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about
strategies to prevent crises, what measures should the nurse recommend?
A)
Using prophylactic antibiotics and performing meticulous hygiene
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B)
Maximizing physical activity and taking OTC iron supplements
C)
Limiting psychosocial stress and eating a high-protein diet
D)
Avoiding cold temperatures and ensuring sufficient hydration
Ans:
D
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Feedback:
Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and
severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing
activity may exacerbate pain and be unrealistic.
24. A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to
the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of
the nurses assessment questions relates most directly to this patients hematologic disorder?
A)
When did you last have a blood transfusion?
B)
What medications have taken recently?
C)
Have you been under significant stress lately?
D)
Have you suffered any recent injuries?
Ans:
B
Feedback:
Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by
medications. Blood transfusions, stress, and injury are less common triggers.
25. A patients electronic health record notes that he has previously undergone treatment for secondary
polycythemia. How should this aspect of the patients history guide the nurses subsequent assessment?
A)
The nurse should assess for recent blood donation.
B)
The nurse should assess for evidence of lung disease.
C)
The nurse should assess for a history of venous thromboembolism.
D)
The nurse should assess the patient for impaired renal function.
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B
Feedback:
Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia. Blood donation
does not precipitate this problem and impaired renal function typically causes anemia, not polycythemia.
A history of VTE is not a likely contributor.
26. A patients absolute neutrophil count (ANC) is 440/mm3. But the nurses assessment reveals no apparent
signs or symptoms of infection. What action should the nurse prioritize when providing care for this
patient?
A)
Meticulous hand hygiene
B)
Timely administration of antibiotics
C)
Provision of a nutrient-dense diet
D)
Maintaining a sterile care environment
Ans:
A
Feedback:
Providing care for a patient with neutropenia requires that the nurse adhere closely to standard
precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic
antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is
highly beneficial, but hand hygiene is the central aspect of care.
27. A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding
disorder. What topic should the nurse prioritize when teaching this patient?
A)
Avoiding buses, subways, and other crowded, public sites
B)
Avoiding activities that carry a risk for injury
C)
Keeping immunizations current
D)
Avoiding foods high in vitamin K
Ans:
B
Feedback:
Patients with bleeding disorders need to understand the importance of avoiding activities that increase
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the risk of bleeding, such as contact sports. Immunizations involve injections and may be
contraindicated for some patients. Patients with bleeding disorders do not need to normally avoid
crowds. Foods high in vitamin K may beneficial, not detrimental.
28. A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When
planning this residents care, the nurse should include which of the following?
A)
Housing the resident in a private room
B)
Implementing a passive ROM program to compensate for activity limitation
C)
Implementing of a plan for fall prevention
D)
Providing the patient with a high-fiber diet
Ans:
C
Feedback:
To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does
not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary
and there is no reason to increase fiber intake.
29. The results of a patients most recent blood work and physical assessment are suggestive of immune
thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following
potential causes? Select all that apply.
A)
Hepatitis
B)
Acute renal failure
C)
HIV
D)
Malignant melanoma
E)
Cholecystitis
Ans:
A, C
Feedback:
Viral illnesses have the potential to cause ITP. Renal failure, malignancies, and gall bladder
inflammation are not typical causes of ITP.
30. A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to
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administer platelets, stating, I have low platelets, so why not give me a transfusion of exactly what Im
missing? How should the nurse best respond?
A)
Transfused platelets usually arent beneficial because theyre rapidly destroyed in the body.
B)
A platelet transfusion often blunts your bodys own production of platelets even further.
C)
Finding a matching donor for a platelet transfusion is exceedingly difficult.
D)
A very small percentage of the platelets in a transfusion are actually functional.
Ans:
A
Feedback:
Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be
ineffective not because the platelets are nonfunctional but because the patients antiplatelet antibodies
bind with the transfused platelets, causing them to be destroyed. Matching the patients blood type is not
usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet
production.
A client with several chronic health problems has been newly diagnosed with a qualitative platelet
31. defect. What component of the patients previous medication regimen may have contributed to the
development of this disorder?
A)
Calcium carbonate
B)
Vitamin B12
C)
Aspirin
D)
Vitamin D
Ans:
C
Feedback:
Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet
aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium,
vitamin D, and vitamin B12 do not have the potential to induce a platelet defect.
32. A young man with a diagnosis of hemophilia A has been brought to emergency department after
suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the
patients bleeding and established that his vital signs are stable. What should be the nurses next action?
A)
Position the patient in a prone position to minimize bleeding.
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B)
Establish IV access for the administration of vitamin K.
C)
Prepare for the administration of factor VIII.
D)
Administer a normal saline bolus to increase circulatory volume.
Ans:
C
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Feedback:
Injuries in patients with hemophilia necessitate prompt administration of clotting factors. Vitamin K is
not a treatment modality and a prone position will not be appropriate for all types and locations of
wounds. A normal saline bolus is not indicated.
33. A nurse is planning the care of a patient who has a diagnosis of hemophilia A. When addressing the
nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurses
choice of interventions?
A)
Gabapentin (Neurontin) is effective because of the neuropathic nature of the patients pain.
B)
Opioids partially inhibit the patients synthesis of clotting factors.
C)
Opioids may cause vasodilation and exacerbate bleeding.
D)
NSAIDs are contraindicated due to the risk for bleeding.
Ans:
D
Feedback:
NSAIDs may be contraindicated in patients with hemophilia due to the associated risk of bleeding.
Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with
hemophilia is not neuropathic.
34. A night nurse is reviewing the next days medication administration record (MAR) of a patient who has
hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the
administration of a PRN antiemetic. What is the nurses best action?
A)
Ensure that the day nurse knows not to give the antiemetic.
B)
Contact the prescriber to have the subcutaneous option discontinued.
C)
Reassess the patients need for antiemetics.
D)
Remove the subcutaneous route from the patients MAR.
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B
Feedback:
Injections must be avoided in patients with hemophilia. Consequently, the nurse should ensure that the
prescriber makes the necessary change. The nurse cannot independently make a change to a patients
MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse.
35. A patient with Von Willebrand disease (vWD) has experienced recent changes in bowel function that
suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of
this procedure?
A)
The patient should not undergo the normal bowel cleansing protocol prior to the procedure.
B)
The patient should receive a unit of fresh-frozen plasma 48 hours before the procedure.
C)
The patient should be admitted to the surgical unit on the day before the procedure.
D)
The patient should be given necessary clotting factors before the procedure.
Ans:
D
Feedback:
A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive
procedure to prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not
reduce the patients risk of bleeding. There may or may not be a need for preprocedure hospital
admission.
36. A patients low prothrombin time (PT) was attributed to a vitamin K deficiency and the patients PT
normalized after administration of vitamin K. When performing discharge education in an effort to
prevent recurrence, what should the nurse emphasize?
A)
The need for adequate nutrition
B)
The need to avoid NSAIDs
C)
The need for constant access to factor concentrate
D)
The need for meticulous hygiene
Ans:
A
Feedback:
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Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K
synthesis and clotting factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not
related to the onset or prevention of vitamin K deficiency.
37. A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally
overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for
what antidote?
A)
IVIG
B)
Factor X
C)
Vitamin K
D)
Factor VIII
Ans:
C
Feedback:
Vitamin K is administered as an antidote for warfarin toxicity.
38. An intensive care nurse is aware of the need to identify patients who may be at risk of developing
disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the
highest risk of DIC?
A)
A patient with extensive burns
B)
A patient who has a diagnosis of acute respiratory distress syndrome
C)
A patient who suffered multiple trauma in a workplace accident
D)
A patient who is being treated for septic shock
Ans:
D
Feedback:
Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is
specifically identified as a cause.
39. A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for
Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating
to this diagnosis are being met?
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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Assess for edema.
B)
Assess skin integrity frequently.
C)
Assess the patients level of consciousness frequently.
D)
Closely monitor intake and output.
Ans:
D
656
Feedback:
The patient with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the
effectiveness of care by closely monitoring the patients intake and output. Each of the other assessments
is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake
and output.
40. A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding
suggests to the nurse that treatment is effective?
A)
The patients PT is within reference ranges.
B)
Arterial blood sampling tests positive for the presence of factor XIII.
C)
The patients platelet level is below 100,000/mm3.
D)
The patients activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
Ans:
D
Feedback:
The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted
to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the
basis of platelet levels, the presence or absence of clotting factors, or PT levels.
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