A client diagnosed with a pulmonary embolism is placed on a continuous Heparin infusion. A nurse should notify the health care provider for which of the following findings?

Client develops ecchymosis at the venipuncture site

PTT 70 seconds (control 25-40)

Client develops hematuria

Order for Coumadin 2.5 mg to begin today

Answer and Explanation

The Correct Answer is C

A. Client develops ecchymosis at the venipuncture site. Minor bruising at venipuncture sites is a common and expected side effect of heparin therapy due to its anticoagulant effect. While the nurse should monitor for increased bruising, isolated ecchymosis at an IV site does not necessarily indicate excessive anticoagulation or require immediate provider notification.
B. PTT 70 seconds (control 25-40). Heparin therapy is adjusted based on the activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5 to 2.5 times the control value, which in this case would be approximately 60-100 seconds. A PTT of 70 seconds is within the therapeutic range, so it does not require urgent intervention.
C. Client develops hematuria. Hematuria is a sign of potential excessive anticoagulation or internal bleeding, which can be a serious complication of heparin therapy. This finding suggests that the client's coagulation status may need immediate reassessment, and the heparin infusion may require adjustment or reversal with protamine sulfate if necessary. The healthcare provider should be notified promptly.
D. Order for Coumadin 2.5 mg to begin today. It is common practice to start warfarin (Coumadin) while a client is on heparin therapy because warfarin takes several days to reach therapeutic levels. Heparin is typically continued until the INR reaches a therapeutic range. Therefore, this order does not require provider notification.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Pneumonia: The client's chest x-ray shows right lower lobe opacity, which is indicative of pneumonia. The presence of thick yellow secretions, coarse crackles, and diminished breath sounds in the right lower lobe further supports this diagnosis. Additionally, the client's increased temperature (39.4°C) and respiratory rate (24/min) are consistent with an infectious process such as pneumonia.

Hypoxia: The client exhibits hypoxia, as evidenced by the oxygen saturation (SaO2) levels of 88% and 92% while receiving 40% humidified oxygen. The dusky appearance of the buccal mucosa is a visible sign of inadequate oxygenation. Hypoxia is a critical condition that can arise from pneumonia due to impaired gas exchange in the lungs.

Angina: Angina refers to chest pain or discomfort due to inadequate blood supply to the heart muscle, typically caused by coronary artery disease. In this case, there is no mention of chest pain or other cardiac symptoms in the client’s notes. Therefore, while angina could be a concern in patients with respiratory distress due to potential cardiac strain, it is not relevant in this scenario based on the provided information.

Stage II Hypertension: Stage II hypertension is characterized by blood pressure readings of 140/90 mm Hg or higher. The client’s blood pressure reading of 128/76 mm Hg does not indicate hypertension; it falls within the normal range. Therefore, this condition is not applicable in this case. While it is important to monitor blood pressure in all patients, it is not relevant to the client’s current respiratory issues.

Correct Answer is ["4"]

Explanation

Formula:

Volume to administer (mL) = (Desired dose (mg) / Available concentration (mg/mL))

Desired dose = 1.6 mg

Available concentration = 2 mg / 5 mL

Calculate the concentration per mL:

2 mg / 5 mL = 0.4 mg/mL

Volume to administer = 1.6 mg / 0.4 mg/mL

= 4 mL

The nurse should administer 4 mL per dose.

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A client diagnosed with a pulmonary embolism is placed on a continuous Heparin infusion. A nurse should notify the health care provider for which of the following findings?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client has manifestations of dropdownanddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

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