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

rheumatoid arthritis

Thalassemia

Thrombocytopenia

Answer and Explanation

The Correct Answer is D

Thrombocytopenia is a condition where the blood has a low platelet count, which can impair blood clotting and increase the risk of bleeding. Heparin is an anticoagulant that prevents blood clots from forming or growing, but it can also cause or worsen thrombocytopenia and bleeding.

Therefore, heparin is contraindicated for clients who have thrombocytopenia or are at risk of developing it. The other conditions are not contraindications to receiving heparin.

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Correct Answer is C

Explanation

The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.

Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.

A. Position the mouthpiece 2.5 cm (1 in) from the mouth. B. Exhale slowly through pursed lips. C. Hold breaths about 3 to 5 seconds before exhaling. D. Place hands on the upper abdomen during inhalation.

Correct Answer is C

Explanation

An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.

Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

Correct Answer is C

Explanation

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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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?