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 B

Explanation

Choice A reason: Leg numbness is not a typical symptom of thyroid dysfunction and may be related to other conditions such as peripheral neuropathy.

Choice B reason: Cold sensitivity is a common symptom of hypothyroidism and warrants evaluation of thyroid function.

Choice C reason: Slow weight loss is not a typical symptom of thyroid dysfunction; unexplained weight gain is more indicative of hypothyroidism.

Choice D reason: Muscle weakness can be associated with various conditions, but cold sensitivity is more specific to thyroid issues.

A. Evaluate the UAP for signs of improvement. B. Discuss the issue privately with the UAP. C. Note date and time of the behavior. D. Plan for scheduled break times.

Correct Answer is C,B,D,A

Explanation

The correct order is:

Note date and time of the behavior.
Discuss the issue privately with the UAP.
Plan for scheduled break times.
Evaluate the UAP for signs of improvement.

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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

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is C,B,D,A

Explanation

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