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.

Nursing Test Bank

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Correct Answer is A

Explanation

Rationale:

A. Encouraging the client to participate in the cardiac rehab program is important for recovery and returning to an active lifestyle.

B. Acknowledging the doctor's expertise is important, but it does not address the client's concerns.

C. This statement may minimize the client's concerns and is not the best response.

D. This statement is not specific and may not address the client's concerns.

A. Suggest that the client use a salt substitute. B. Advise the client to add citrus juices and bananas to her diet. C. Obtain a 12-lead ECG D. Obtain a blood sample for a serum sodium level

Correct Answer is C

Explanation

Rationale:

A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.

B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.

C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.

D. A serum sodium level should be obtained but it is not the priority in this case.

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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 caring for a client post transcatheter aortic valve replacement (TAVR). During the first cardiac rehabilitation session, the client tells the nurse, "I do not need to be here. I am feeling so much better, I can do this at home". Which of the following is the appropriate nursing response?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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Identify the following Cardiac Rhythm:

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