A nurse is caring for a client who is receiving an IV infusion of heparin. Which of the following findings should indicate to the nurse the client is at risk for hemorrhage? (Select all that apply.)
Thrombocytopenia.
Neutropenia.
Hypokalemia.
Fever.
Hyperglycemia.
Dark stools.
Correct Answer : A,F
Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale
Monitoring glucose levels is not typically necessary for patients receiving gentamicin, as it does not significantly affect glucose metabolism.
Choice B rationale
Prothrombin time is not commonly affected by gentamicin, so routine monitoring is not required.
Choice C rationale
Serum creatinine levels should be monitored to assess kidney function, as gentamicin can cause nephrotoxicity.
Choice D rationale
Cardiac enzymes are not typically affected by gentamicin, so routine monitoring is not necessary.
Choice E rationale
Monitoring WBC count is important to detect any signs of infection or bone marrow suppression, which can occur with gentamicin use.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The client is at risk for developing cardiac arrhythmia due to hypokalemia.
Hypokalemia (low potassium levels) can lead to cardiac arrhythmias, which are irregular heartbeats. The client’s potassium level is 3.1 mEq/L, which is below the normal range (3.5-5.0 mEq/L). This, combined with his symptoms of dizziness, palpitations, and weakness, indicates a risk for developing cardiac arrhythmias.
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