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 ["C","D","E"]

Explanation

Choice A reason: Standard precautions and wearing a mask are important but not sufficient alone for MRSA infection control.

Choice B reason: A low bacteria diet is not specifically indicated for osteomyelitis or MRSA infection.

Choice C reason: Contact precautions are essential to prevent the spread of MRSA.

Choice D reason: Sending wound drainage for culture and sensitivity helps identify the causative organism and guide antibiotic therapy.

Choice E reason: Monitoring the white blood cell count helps assess the client's response to infection and treatment.

A. Relevance to the situation. B. Related personal values. C. Frequency that the problem occurs. D. Past experience with similar problems.

Correct Answer is A

Explanation

Choice A reason: Relevance to the situation is the most important consideration when gathering evidence to ensure that the information directly addresses the specific clinical question and problem at hand.

Choice B reason: Related personal values are important but secondary to the relevance of evidence in making clinical decisions.

Choice C reason: Frequency that the problem occurs is useful information but not as crucial as ensuring the evidence is directly relevant.

Choice D reason: Past experience with similar problems can inform decision-making but should be supported by relevant and current evidence.

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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.

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Naxlex Comprehensive Predictor Exams

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

Correct Answer is A

Explanation

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