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 D
Explanation
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.
Correct Answer is B
Explanation
A. Hamburger on a bun, banana: This choice is high in protein and potassium, which may not be suitable for someone with chronic renal disease, as excessive potassium intake can be harmful to individuals with impaired kidney function.
B. Carrots, green leafy vegetables, a pear: This choice is low in potassium and phosphorus, making it suitable for someone with chronic renal disease. Carrots and green leafy vegetables are generally lower in potassium, and a pear is a low-potassium fruit option.
C. Spaghetti with meat sauce, breadstick: This choice may be high in protein and sodium, depending on the sauce and breadstick ingredients, which may not be ideal for someone with chronic renal disease.
D. Cold cuts with bun, blueberries: Cold cuts can be high in sodium, and blueberries are moderately high in potassium, so this choice may not be appropriate for someone with chronic renal disease.
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