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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.

A. "I will increase the amount of fresh fruits and vegetables I consume.". B. "I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash.". C. "I will be sure to wear gloves and wash my hands when I change my cat's litter box.". D. "I will need to take my clothes to the dry cleaners to sterilize them.".

Correct Answer is C

Explanation

This statement indicates an understanding of the teaching because it shows that the client is aware of the importance of reducing their risk of infection by taking precautions when handling pet waste.

Choice A is wrong because while increasing the amount of fresh fruits and vegetables consumed is a healthy dietary choice, it does not demonstrate an understanding of the discharge teaching for a client with AIDS.
Choice B is wrong because while cleaning up areas soiled with body fluids is important, using alcohol and immediately disposing of the trash is not necessary.
Choice D is wrong because taking clothes to the dry cleaners to sterilize them is not necessary for a client with AIDS.

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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

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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?