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.

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

Explanation

A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.

B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.

C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.

D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.

E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.

A. Check an apical pulse B. Request a dietitian consult. C. Request an order for an antiemetic D. Suggest that the client rests before eating the meal

Correct Answer is A

Explanation

A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.

B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.

C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.

D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority

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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?

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Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is A

Explanation

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