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    Ati vati adult med surgical proctored exam

    A nurse is caring for a female client who has deep-vein thrombosis (DVT) and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb) Exhibits Using the client information provided, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.)

    Explanation & Rationale

    Rationale: A. Stop the heparin infusion for 1 hr: The client’s aPTT is 105 seconds, which is above the protocol threshold of >95 seconds. Per the titration guidelines, the nurse should hold the infusion for 60 minutes and decrease the rate by 3 units/kg/hr after the hold to reduce bleeding risk. B. Increase the rate of the infusion by 160 units/hr: Increasing the infusion is appropriate only when aPTT is between 30–49 seconds. Since this client's aPTT is elevated, increasing the rate would further prolong clotting time and increase the risk of hemorrhage. C. Administer heparin 2,400 unit IV bolus: Bolus doses are prescribed only for low aPTT values (30–49 seconds). Giving a bolus when aPTT is elevated can worsen anticoagulation and significantly increase the potential for bleeding complications. D. Continue the infusion without change: Continuing the infusion is appropriate when aPTT is within the therapeutic range (50–70 seconds). This client’s aPTT is well above that range, indicating excessive anticoagulation that requires adjustment.

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