A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

Explanation

B.Hypertension

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.

Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.

The other options are not specifically associated with the adverse effects of tranylcypromine:

Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.

Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.

Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.

This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.

After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.

Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.

Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.

Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.

The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:

1. Inject air into the NPH insulin vial (in this case, 10 units of air).
2. Inject air into the regular insulin vial (in this case, 15 units of air).
3. Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
4. Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.

So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.