hard · NCLEX-RN Reduction of Risk Potential
A nurse is caring for a client with a deep vein thrombosis (DVT) who is receiving a continuous heparin infusion. The client's latest aPTT is 110 seconds (reference range: 30 to 40 seconds). Which actions should the nurse take? Select all that apply.
- Stop the heparin infusion immediately and notify the provider.
- Assess the client for new cues of bleeding, such as hematuria or bruising.
- Prepare to administer protamine sulfate if ordered.
- Encourage the client to ambulate to prevent further clot formation.
- Continue the infusion at the current rate and recheck the aPTT in 6 hours.
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