Page 1807 - Saunders Comprehensive Review For NCLEX-RN

Rationale: When a client is receiving warfarin for clot prevention due to atrial
fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has
achieved a therapeutic range, the client should be maintained on a continuous
heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the
nurse should collaborate with the HCP to obtain a prescription to increase the
heparin infusion and to administer the warfarin as prescribed.
Test-Taking Strategy: Focus on the subject, laboratory result analysis related to
these medications. First, eliminate the option that indicates to discuss use of
dabigatran etexilate, recalling that it is contraindicated for use in atrial fibrillation
associated with valvular heart disease. Next, recall that if the warfarin sodium has
achieved the therapeutic range for the INR for clot prevention in atrial fibrillation,
the heparin infusion is no longer necessary. This will help you eliminate the option
that indicates to withhold the warfarin sodium because the INR is not therapeutic.
Last, keep in mind that if both the aPTT and the INR are not within therapeutic
range, the client is left unprotected from clot formation.
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pharmacology: Cardiovascular Medications: Anticoagulants
Health Problem: Adult Health: Cardiovascular: Dysrhythmias
Priority Concepts: Clotting; Collaboration
Reference: Burchum, Rosenthal (2016), pp. 621-623.

631. Answer: 3

Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a
complication of any type of thrombolytic medication. The client is monitored for
bleeding. Monitoring for renal failure and monitoring the client’s psychosocial status
are important but are not the most critical interventions. Heparin may be
administered after thrombolytic therapy, but the question is not asking about follow-
up medications.
Test-Taking Strategy: Note the strategic word, priority. Remember that bleeding is
a priority for thrombolytic medications.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pharmacology: Cardiovascular Medications: Thrombolytics
Health Problem: Adult Health: Cardiovascular: Myocardial infarction
Priority Concepts: Clotting; Safety
Reference: Burchum, Rosenthal (2016), pp. 617-618.

632. Answer: 1, 3, 5, 6

Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based
medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also,
clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia,
and hyperuricemia.

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