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?
Thrombocytopenia.
Rheumatoid arthritis.
Thalassemia.
COPD.
The Correct Answer is A
Thrombocytopenia, or low platelet count, is a contraindication to receiving heparin.
Rheumatoid arthritis is not a contraindication to receiving heparin.
Thalassemia is not a contraindication to receiving heparin.
COPD is not a contraindication to receiving heparin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is D
Explanation
Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.
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