A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Review last partial thromboplastin time (PTT) results.

Auscultate bowel sounds in all quadrants.

Monitor stools for presence of blood.

Prepare to administer warfarin.

Assess characteristics of pain.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason: Reviewing the last PTT results is important to ensure that the heparin therapy is within the therapeutic range and to assess for potential over-anticoagulation.

Choice B reason: Auscultating bowel sounds in all quadrants helps determine if there is any bowel obstruction or ileus, which can be associated with abdominal pain.

Choice C reason: Monitoring stools for the presence of blood is essential to identify gastrointestinal bleeding, which can present as tarry, black stools.

Choice D reason: Preparing to administer warfarin is not appropriate in the acute management of potential gastrointestinal bleeding and should be done based on the healthcare provider's instructions.

Choice E reason: Assessing the characteristics of pain is important to better understand the cause of abdominal pain and guide further management.

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Correct Answer is A

Explanation

Choice A reason: Administering cefazolin, an antibiotic, is a priority to prevent or treat potential infections in the immediate postoperative period.

Choice B reason: Completing a CBC in the morning is important for ongoing assessment but is not an immediate priority.

Choice C reason: Advancing the diet as tolerated is important but can be done after ensuring infection prevention.

Choice D reason: Straight catheterization is necessary if the client is unable to void but is not the immediate priority compared to preventing infection.

A. Report the client's jaw pain to the healthcare provider. B. Advise the client to gargle with warm salt water twice daily. C. Determine how the client is administering the medication. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is A

Explanation

Choice A reason: Reporting the client's jaw pain to the healthcare provider is essential because jaw pain can be a symptom of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate therapy.

Choice B reason: Advising the client to gargle with warm salt water may provide temporary relief, but it does not address the underlying issue of potential osteonecrosis.

Choice C reason: Determining how the client is administering the medication is important for proper use but does not address the immediate concern of jaw pain.

Choice D reason: Confirming that this is a common symptom of osteoporosis is incorrect. Jaw pain is not a common symptom of osteoporosis and requires further evaluation.

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A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is A

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is A

Explanation

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