A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?
The patient’s PTT is 70 seconds (control 25-40).
The patient develops ecchymosis at the venipuncture site.
The patient develops hematuria.
There is an order for Coumadin 2.5 mg to start today.
Correct Answer : A,C,D
Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Performing an opening move is an initial step in the negotiation process where each party presents their initial demands or offers. This is not the step the nurse manager is using in this scenario.
Choice B rationale
Continuing the negotiation involves ongoing discussions and adjustments to reach a mutually beneficial agreement. This is not the step the nurse manager is using in this scenario.
Choice C rationale
Clarifying the problem involves understanding and defining the issues at hand. While this is an important step in the negotiation process, it is not the step the nurse manager is using in this scenario.
Choice D rationale
Setting ground rules involves establishing the guidelines for how the negotiation will be conducted. In this scenario, the nurse manager is setting ground rules by inviting the staff to each take a turn speaking and requesting that everyone listen respectfully and refrain from making personal or professional comments about one another.
Correct Answer is B
Explanation
Choice A rationale
While immunosuppressive drug therapy can facilitate organ rejection, it is not directly related to the development of chronic rhinosinusitis in patients who have undergone organ transplants.
Choice B rationale
Immunosuppressive drug therapy can indeed contribute to chronic rhinosinusitis. Patients who have undergone organ transplants are often on long-term immunosuppressive therapy to prevent organ rejection. This can make them more susceptible to infections, including chronic rhinosinusitis.
Choice C rationale
Chronic rhinosinusitis does not typically damage the transplanted organ. It primarily affects the sinuses and nasal passages.
Choice D rationale
All of the above is not the correct answer because Choices A and C are not accurate in the context of chronic rhinosinusitis in patients who have undergone organ transplants.
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