A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

Thalassemia

Rheumatoid arthritis

Thrombocytopenia

COPD

Answer and Explanation

The Correct Answer is C

A. Thalassemia: A genetic blood disorder affecting hemoglobin production. While patients with severe anemia may have an increased bleeding risk, thalassemia itself is not a contraindication to heparin. Caution is needed if the patient has splenomegaly or significant anemia.

B. Rheumatoid arthritis: An autoimmune condition that can increase bleeding risk due to chronic inflammation and medication use, such as NSAIDs or corticosteroids. However, heparin is not contraindicated unless there is an associated bleeding disorder or severe thrombocytopenia.

C. Thrombocytopenia: A condition characterized by a low platelet count, significantly increasing the risk of bleeding. Heparin use can worsen this condition, especially in cases of heparin-induced thrombocytopenia (HIT), which can lead to both bleeding and thrombosis.

D. COPD: A chronic lung disease that does not directly contraindicate heparin therapy. While COPD patients may be at risk for deep vein thrombosis due to immobility, heparin remains a standard prophylactic treatment unless there are other bleeding risks.

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Correct Answer is B

Explanation

A. Provide a diet of fresh fruits and vegetables for the client: While a high-protein, high-calorie diet is essential for wound healing in burn patients, fresh fruits and vegetables may not be appropriate if the client is immunocompromised due to the risk of bacterial contamination. Cooked or peeled produce is often recommended.

B. Apply new gloves when alternating between wound care sites: Burn wounds are highly susceptible to infection. Changing gloves between different wound sites prevents cross-contamination and reduces the risk of spreading bacteria, which is critical in preventing wound infections and sepsis.

C. Clean the equipment in the client's room once per week: Equipment in a burn unit should be cleaned and disinfected daily to minimize the risk of infection. Weekly cleaning is insufficient for infection control in an immunocompromised client.

D. Limit visitation time for the client's children to 40 min per day: While infection control is a priority, limiting visitation is not typically necessary unless the visitors are ill. Emotional support from family can aid in psychological recovery, and proper infection control measures can be implemented without strict visitation limits.

A. Wears an N95 mask when providing wound care B. Wears clean gloves when caring for the client C. Remains 3 feet away from the client D. Disposes of isolation gown outside of the client's room

Correct Answer is B

Explanation

A. Wears an N95 mask when providing wound care: MRSA is transmitted via direct contact rather than airborne particles, so an N95 mask is unnecessary unless the client has a secondary airborne infection like tuberculosis. Standard contact precautions, including gloves and gowns, are sufficient to prevent transmission.

B. Wears clean gloves when caring for the client: MRSA requires contact precautions, which include wearing gloves when touching the client or contaminated surfaces. Gloves help prevent the spread of bacteria, particularly from wound drainage, body fluids, or contaminated equipment.

C. Remains 3 feet away from the client: MRSA does not require droplet precautions, which would necessitate maintaining a distance of 3 feet. Instead, direct skin-to-skin contact or contact with contaminated surfaces is the primary mode of transmission, requiring gloves and gowns rather than distance.

D. Disposes of isolation gown outside of the client's room: Isolation gowns should be removed inside the client’s room to prevent cross-contamination. Removing the gown before exiting the room reduces the risk of spreading MRSA to other areas and healthcare personnel.

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A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

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