Page 328 - Saunders Comprehensive Review For NCLEX-RN

axillary temperature on a client who just consumed coffee is also acceptable;
however, the axillary method of measurement is the least reliable, and other
methods should be used if available. If electronic equipment is available and the
client is diaphoretic, it is acceptable to measure the temperature on the neck behind
the ear, avoiding the forehead.
Test-Taking Strategy: Note the strategic words, need for further teaching. These
words indicate a negative event query and the need to select the incorrect action as
the answer. Recall that nasal congestion is a reason to avoid taking an oral
temperature, as the nasal congestion will cause problems with breathing while the
temperature is being taken.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Skills: Vital Signs
Health Problem: N/A
Priority Concepts: Teaching and Learning; Thermoregulation
Reference: Perry et al. (2018), pp. 68-69.

68. Answer: 4

Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40
seconds), depending on the type of activator used in testing. The therapeutic dose of
heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to
60) and 2.5 (75 to 100) times normal. This means that the client’s value should not be
less than 45 seconds or greater than 100 seconds. Thus, the client’s aPTT is within the
therapeutic range and the dose should remain unchanged.
Test-Taking Strategy: Focus on the subject, the expected aPTT for a client
receiving a heparin sodium infusion. Remember that the normal range is 30 to 40
seconds and that the aPTT should be between 1.5 and 2.5 times normal when the
client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 30 and 40
will yield a range of 45 to 100 seconds. This client’s value is 65 seconds.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Foundations of Care: Laboratory Tests
Health Problem: Adult Health: Cardiovascular: Vascular Disorders
Priority Concepts: Clinical Judgment; Clotting
Reference: Lewis et al. (2017), p. 601.

69. Answer: 1

Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5
to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic
range. Administering furosemide to a client with a low potassium level and a history
of cardiac problems could precipitate ventricular dysrhythmias. The remaining
options are within the normal range.
Test-Taking Strategy: Note the subject of the question, the level that should be

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