Difficulty: Medium
Average Score: 72%
Simulated
A nurse is assessing a client who is receiving heparin via continuous IV. The client has an aPTT of 90 seconds. The nurse should monitor the client for which of the following changes in their vital signs?
Correct answer
D
Rationale
The correct answer is D: Increased pulse rate. Heparin is an anticoagulant medication that prolongs the clotting time by inhibiting thrombin formation. A prolonged aPTT of 90 seconds indicates that the heparin dose may be too high, increasing the risk of bleeding. To compensate for this, the body may increase the heart rate to maintain adequate tissue perfusion. Monitoring for an increased pulse rate is crucial to detect early signs of bleeding or heparin overdose. The other options are incorrect because heparin does not directly affect blood pressure, temperature, or respiratory rate.