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","D"]
Explanation
Choice A rationale
Following ventilator-weaning protocols is an important intervention to prevent ventilator-associated pneumonia. Weaning protocols help to reduce the duration of mechanical ventilation, which is a risk factor for developing ventilator-associated pneumonia.
Choice B rationale
Providing frequent mouth care is a key intervention in preventing ventilator-associated pneumonia. Good oral hygiene can help to reduce the amount of bacteria in the mouth that can potentially be aspirated into the lungs.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a method to prevent ventilator-associated pneumonia. Over-suctioning can potentially damage the lung tissue and mucous membranes, and it can also increase the risk of introducing bacteria into the lungs.
Choice D rationale
Placing the patient in a prone position can help to improve oxygenation and reduce the risk of ventilator-associated pneumonia. The prone position can help to drain secretions from the lungs, reducing the risk of bacteria growth and infection.
Choice E rationale
Refraining from suctioning the patient is not a recommended intervention to prevent ventilator-associated pneumonia. Suctioning is necessary to remove secretions from the airway, which can help to prevent infection.
Correct Answer is D
Explanation
Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.
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