A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?
Client develops petechiae on the arms, legs, and abdomen.
Health care provider orders Coumadin 2.5 mg P.O. to begin today.
Client develops slight ecchymosis at the venipuncture site.
Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds.
The Correct Answer is D
A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.
B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.
C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.
D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Increase your intake of grapefruit juice."
Grapefruit juice can interact with many medications, including colchicine, potentially increasing the risk of adverse effects or reducing its effectiveness. Therefore, it is not recommended to increase grapefruit juice intake while taking colchicine.
B. "Expect to have increased generalized bruising." Increased bruising is not a common side effect of colchicine.
C. "Monitor for muscle pain."
Colchicine is associated with myotoxicity, which can manifest as muscle pain or weakness. Therefore, the client should be instructed to monitor for signs and symptoms of muscle pain and report them promptly to their healthcare provider.
D. "Take this medication without food if nausea develops."
While colchicine can cause gastrointestinal side effects such as nausea and vomiting, taking it without food may exacerbate these symptoms. It is generally recommended to take colchicine with food to minimize gastrointestinal upset.
Correct Answer is B
Explanation
A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.
B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.
C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.
D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.
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