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 A
Explanation
Choice A rationale
The nurse’s actions are an example of Quality Improvement. Quality Improvement involves systematic actions that lead to measurable improvement in health care services and the health status of targeted patient groups. In this case, the nurse identified a problem (increase in pressure injuries), collected data (documented findings), and implemented a change (new policy for consistent use of a pressure injury risk assessment scale) to improve patient outcomes.
Choice B rationale
While collaboration was part of the process (the nurse collaborated with the manager), the overall actions taken represent a Quality Improvement process.
Choice C rationale
Case Management typically involves coordinating the care and services of select patient populations, such as those with chronic illnesses or complex health needs. It does not directly apply to this scenario.
Choice D rationale
Advocacy involves supporting or promoting the interests of others, such as patients or colleagues. Although the nurse’s actions could be seen as advocating for the patients’ well- being, the term that best characterizes these actions is Quality Improvement.
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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