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?

COPD

Thalassemia

Thrombocytopenia

Rheumatoid arthritis

Answer and Explanation

The Correct Answer is C

Choice A Reason:

COPD (Chronic Obstructive Pulmonary Disease) - While COPD might influence the choice of anaesthesia and perioperative management, it is not a direct contraindication to heparin.

Choice B Reason:

Thalassemia - Thalassemia is a genetic blood disorder that affects haemoglobin production and the structure of red blood cells. It does not directly impact the ability to receive heparin.

Choice C Reason:

Thrombocytopenia. Thrombocytopenia, which is a low platelet count, is a contraindication to receiving heparin, an anticoagulant. Heparin works by preventing the formation of blood clots, but if a person has a low platelet count, their ability to form blood clots is already compromised. Administering heparin in this situation could increase the risk of bleeding and further reduce platelet count.

Choice D Reason:

Rheumatoid arthritis - Rheumatoid arthritis is an autoimmune condition affecting joints. It is not a contraindication to heparin use, but the client's overall health and medications should be considered when planning surgery and anticoagulant therapy.

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Correct Answer is B

Explanation

Choice A reason:

"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.

Choice B reason:

“will have to wait 2 months before additional saline can be added to my breast expander" This is the correct statement. Following a modified radical mastectomy with a breast expander, additional saline is often added gradually to the expander to stretch the skin and muscle for reconstruction. The waiting period between saline additions allows for healing and proper tissue expansion. This statement indicates that the client understands the postoperative care and timeline.

Choice C reason:

"should expect less than 25 ml of secretions per day in the drainage devices": This statement is not accurate because the drainage amount can vary, and 25 ml per day might not be an accurate estimate.

Choice D reason:

"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.

A. The client reports being extremely thirsty with a sore throat. B. The client's abdomen becomes distended and firm. C. The drainage is bright green in color with brown fecal material D. The amount of drainage is gradually decreasing

Correct Answer is C

Explanation

Choice A Reason:

The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.

Choice B Reason:

The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.

Choice C Reason:

The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.

Choice D Reason:

The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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