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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assess the insertion site: Assessing the insertion site for bleeding, hematoma, or signs of infection is the priority action because complications at the insertion site can occur post- procedure and require immediate attention.

B. Keep the client NPO for 4 hr: Keeping the client NPO is not typically necessary after a cardiac catheterization unless there are specific orders or complications.

C. Keep the affected leg slightly flexed: The affected leg should actually be kept straight to prevent bleeding from the insertion site.

D. Elevate the head of the bed 45°: The head of the bed should usually be kept flat or only slightly elevated to reduce the risk of bleeding from the femoral site.

A. "After the surgery, I will have to be careful with heavy lifting for a few weeks." B. "I know that after the surgery, I will only have one testicle left." C. "I will have to take antibiotics as prescribed by my doctor to prevent infection." D. "I will need to avoid showering for a month after the surgery."

Correct Answer is D

Explanation

A. "After the surgery, I will have to be careful with heavy lifting for a few weeks": This statement demonstrates understanding of postoperative precautions, as heavy lifting can strain the surgical site and delay healing.

B. "I know that after the surgery, I will only have one testicle left": This statement indicates awareness of the surgical procedure and its potential outcomes, which is accurate.

C. "I will have to take antibiotics as prescribed by my doctor to prevent infection": This statement reflects understanding of the importance of antibiotic therapy to prevent postoperative infection, which is correct.

D. "I will need to avoid showering for a month after the surgery": This statement is incorrect.

Avoiding showering for a month after surgery is unnecessary and could lead to poor hygiene and potential complications such as infection. The client should be educated that showering is typically allowed after surgery, but they should avoid soaking the incision site in water until it has healed properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client arriving to the unit following a cardiac catheterization with a right femoral insertion site. Which of the following is the nurse's priority action?

Correct Answer is A

Explanation

A nurse is educating a client who was diagnosed with left testicular cancer and is scheduled for an orchiectomy. Which statement made by the client would require further teaching?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with pulmonary embolism. Which new-onset assessment finding should a nurse expect in a client diagnosed with a pulmonary embolism?

A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)

A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

A student nurse is learning about client safety. The student nurse should recognize that which of the following is true regarding client safety and prevention of harm?

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

A nurse is caring for a client who is scheduled for chemotherapy due to bone metastasis of prostate cancer. Which of the following statements about chemotherapy made by the nurse is correct?

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

A nurse is caring for a client admitted with a diagnosis of acute kidney injury. The client asks the nurse, "Are my kidneys failing and will I need a kidney transplant?" The nurse should respond to the client with which of the following statements?