hard · NCLEX-RN risk-reduction

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.

1. Stop the heparin infusion immediately and notify the provider.
2. Assess the client for new cues of bleeding, such as hematuria or bruising.
3. Prepare to administer protamine sulfate if ordered.
4. Encourage the client to ambulate to prevent further clot formation.
5. Continue the infusion at the current rate and recheck the aPTT in 6 hours.

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