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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Oprelvekin (Neumega): Oprelvekin is a recombinant human interleukin-11 (IL-11) used to stimulate the production of platelets, not red blood cells. It is primarily indicated for patients with thrombocytopenia (low platelet count) due to chemotherapy.
B. Epoetin alfa (Procrit): Epoetin alfa is a synthetic form of erythropoietin, a hormone produced by the kidneys that stimulates the production of red blood cells in the bone marrow. It is commonly used to treat anemia associated with chronic kidney disease, chemotherapy, or HIV therapy. Therefore, it is administered to increase the number of circulating red blood cells.
C. Clopidogrel (Plavix): Clopidogrel is an antiplatelet medication that inhibits platelet aggregation, thereby reducing the risk of blood clots. It does not directly stimulate the production of red blood cells.
D. Filgrastim (Neupogen): Filgrastim is a recombinant human granulocyte colony-stimulating factor (G-CSF) that stimulates the production of white blood cells, particularly neutrophils, in the bone marrow. It is used to treat neutropenia (low white blood cell count) caused by chemotherapy, bone marrow transplantation, or certain diseases. It does not directly stimulate the production of red blood cells.
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