A patient has been taking heparin for three days and has developed hematuria. The most appropriate action for the nurse is to:

Insert a urinary catheter to determine the residual urine

Hold the next dose of heparin and contact the physician

Instruct the patient to drink adequate amounts of fluid

Administer an additional dose of heparin subcutaneously

Answer and Explanation

The Correct Answer is B

A. Insert a urinary catheter to determine the residual urine. Inserting a urinary catheter may be necessary to accurately measure urinary output and assess for signs of urinary retention. However, the presence of hematuria suggests a potential bleeding complication related to heparin therapy. While monitoring urinary output is important, inserting a urinary catheter should not be the first action taken in response to hematuria. Other interventions to address the bleeding should be prioritized.

B. Hold the next dose of heparin and contact the physician. This is the correct answer. Hematuria can be a sign of a bleeding complication, which is a known side effect of heparin therapy. Holding the next dose of heparin is appropriate to prevent further bleeding, and contacting the physician ensures prompt evaluation and appropriate management of the patient's condition. The physician may decide to adjust the dose of heparin, temporarily discontinue it, or order further investigations to determine the cause of the hematuria.

C. Instruct the patient to drink adequate amounts of fluid. While maintaining hydration is important for overall health, instructing the patient to drink fluids would not directly address the underlying cause of hematuria, which may be related to a bleeding complication from heparin therapy. Holding the next dose of heparin and contacting the physician are more appropriate actions in response to hematuria.

D. Administer an additional dose of heparin subcutaneously. Administering additional heparin would exacerbate the bleeding risk and is contraindicated in the presence of hematuria. It is important to withhold further doses of heparin and seek medical guidance to address the bleeding complication.

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Correct Answer is B

Explanation

A. If he misses a dose, he should double the dose at the next scheduled time: This statement is incorrect. Doubling the dose of warfarin after missing a dose can significantly increase the risk of bleeding due to excessive anticoagulation. The nurse should emphasize the importance of taking the medication as prescribed and what to do if a dose is missed, such as contacting the healthcare provider for guidance.

B. The client should use an electric razor while on this medication: This statement is correct. Warfarin is an anticoagulant medication that can increase the risk of bleeding. Therefore, it's essential for patients taking warfarin to avoid activities that may increase the risk of injury or bleeding, such as shaving with a traditional razor that can cause cuts or nicks. Using an electric razor reduces this risk.

C. Mild nosebleeds are common during initial treatment: This statement is not entirely accurate. While warfarin can increase the risk of bleeding, including nosebleeds, it's not necessarily common during the initial treatment phase. However, patients should be aware of signs of bleeding and report them to their healthcare provider promptly.

D. Warfarin increases the risk for deep vein thrombosis: This statement is incorrect. Warfarin is actually prescribed to reduce the risk of blood clots, including deep vein thrombosis (DVT), pulmonary embolism (PE), and stroke, in patients who are at risk for these conditions. It works by inhibiting the formation of blood clots. Therefore, it does not increase the risk of DVT; rather, it decreases it.

A. Hypothermia B. Hypotension C. Black stools D. Constipation

Correct Answer is C

Explanation

A. Hypothermia: Clopidogrel is not typically associated with temperature regulation and wouldn't cause hypothermia.

B. Hypotension: While some medications can cause low blood pressure (hypotension), clopidogrel is not a common culprit.

C. Black stools: This can be a sign of upper gastrointestinal bleeding, which is a potential side effect of clopidogrel. Clopidogrel inhibits platelet aggregation, which can increase bleeding risk.

D. Constipation: Constipation is not a common side effect of clopidogrel.

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A patient has been taking heparin for three days and has developed hematuria. The most appropriate action for the nurse is to:

Nursing Test Bank

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