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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
In a client diagnosed with chronic obstructive pulmonary disease (COPD), an arterial blood gas (ABG) test would typically show an increased level of carbon dioxide (PaCO2)56. This is because COPD affects the ability of the lungs to expel carbon dioxide, leading to its buildup in the blood.
Choice B rationale
An increased pH is not typically seen in COPD. In fact, due to the increased carbon dioxide (which is acidic), the pH may be lower, indicating respiratory acidosis.
Choice C rationale
Decreased alveolar function is a characteristic of COPD, but it is not something that would be directly measured in an ABG test.
Choice D rationale
An increased arterial oxygen (PaO2) is not typically seen in COPD. In fact, due to the impaired gas exchange, PaO2 may be lower.

A. Place a tracheostomy tray at the client’s bedside. B. Administer IV prophylaxis for thromboembolism. C. Prepare to assist with intubation of the client. D. Administer IV prophylaxis for stress ulcers.

Correct Answer is C

Explanation

Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.

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A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is analyzing arterial blood gas results for a client diagnosed with chronic obstructive pulmonary disease (COPD). What abnormal finding should the nurse anticipate?

Correct Answer is A

Explanation

A client has been diagnosed in the Emergency Department with acute respiratory distress syndrome (ARDS). Which of the following actions should a nurse perform first?

Correct Answer is C

Explanation

A nurse is reviewing the arterial blood gas (ABG) results for a patient diagnosed with progressive Chronic Obstructive Pulmonary Disease (COPD). Which ABG results should the nurse expect for a patient with progressive COPD?

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