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","B","E"]
Explanation
Choice A rationale
Viral pharyngitis can sometimes lead to serious complications such as peritonsillar abscess. Symptoms of this condition include drooling and inability to fully open the mouth. Therefore, patients should be advised to contact a healthcare provider immediately if they experience these symptoms.
Choice B rationale
Viral pharyngitis is contagious and can be spread through saliva. Therefore, patients should be advised to avoid sharing drinks or eating utensils with others to prevent the spread of the infection.
Choice C rationale
Antibiotics are not effective against viral infections, including viral pharyngitis. Therefore, taking prescribed antibiotics on time and not missing doses is not relevant in the context of viral pharyngitis.
Choice D rationale
Checking the body for skin rash twice daily is not typically necessary for patients with viral pharyngitis. While some viruses can cause a rash, it is not a common symptom of viral pharyngitis.
Choice E rationale
Drinking at least 2-3 liters of fluid per day unless contraindicated can help soothe a sore throat and prevent dehydration, which can occur if the patient has a fever or is not eating well due to the sore throat.
Correct Answer is D
Explanation
Choice A rationale
Taking breaks outside in fresh air can help to clear the lungs of inhaled toxins to some extent. However, this measure alone is not sufficient to prevent inhalation exposure of job-related substances.
Choice B rationale
Consistently wearing a disposable paper mask can provide some protection against inhalable toxins. However, such masks may not be effective against all types of toxins and may not provide complete protection.
Choice C rationale
Keeping a fan blowing in the environment can help to disperse toxic substances and prevent them from becoming stagnant in the air. However, this measure alone may not be sufficient to prevent inhalation exposure, and in some cases, it could even spread the toxins more widely.
Choice D rationale
Wearing designated protective attire and devices when working with a toxic substance is the most effective measure to prevent inhalation exposure. This can include items such as respirators, which are designed to filter out specific toxins and protect the respiratory system.
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