A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

Petechiae

Slowing pulse rate

Confusion

Pruritus

Answer and Explanation

The Correct Answer is A

Rationale:

A. Petechiae are small, pinpoint red or purple spots on the skin that may indicate bleeding or thrombocytopenia, which can be a side effect of heparin therapy.

B. Slowing pulse rate is not typically associated with heparin therapy.

C. Confusion is not typically associated with heparin therapy.

D. Pruritus (itching) is not typically associated with heparin therapy.

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Correct Answer is D

Explanation

A. Regular pacemaker checks are scheduled periodically, not only when the battery needs replacement.
B. Modern pacemakers are well-shielded and are not affected by household microwaves.
C. Clients should check their pulse daily to ensure proper pacemaker function, not just weekly.
D. Many pacemakers can be checked remotely using telephone or wireless technology, allowing for convenient monitoring.

A. Diminished breath sounds B. Increased blood pressure C. Diminished heart sounds D. New systolic murmur

Correct Answer is C

Explanation

Rationale:

A. Diminished breath sounds are not typically associated with a pericardial effusion.

B. Increased blood pressure is not typically associated with a pericardial effusion but it can instead result in hypotension due to decreased cardiac output due to compression of the heart by the accumulated fluid.

C. The heart sounds may become faint or distant due to fluid accumulation around the heart.

D. A new systolic murmur may indicate a pericardial effusion and should be further evaluated.

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A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements indicates to the nurse that the teaching was effective?

Correct Answer is D

Explanation

A nurse is caring for a client in a critical care unit who is 4 hours post operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

Correct Answer is C

Explanation

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A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

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