A patient receiving heparin therapy develops bruising and bleeding gums. What should the nurse suspect and what is the appropriate action?

Suspect an allergic reaction and administer antihistamines.

Suspect a bleeding complication and notify the healthcare provider.

Suspect a hypersensitivity reaction and discontinue the heparin immediately.

Suspect an infection and initiate antibiotic therapy.

Answer and Explanation

The Correct Answer is B

A. Bruising and bleeding gums are not indicative of an allergic reaction, which would typically present with different symptoms such as rash, itching, or swelling. Administering antihistamines would not address the underlying issue.

B. The development of bruising and bleeding gums in a patient on heparin therapy suggests a bleeding complication, which is a known risk of anticoagulation therapy. The nurse should notify the healthcare provider to assess the situation and possibly adjust treatment or perform further evaluations.

C. While hypersensitivity reactions can occur with medications, the symptoms presented here are more aligned with bleeding complications than with hypersensitivity. Discontinuing heparin without consulting the provider could put the patient at risk for thromboembolic events.

D. The symptoms do not indicate an infection; therefore, initiating antibiotic therapy would not be appropriate in this context.

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Correct Answer is B

Explanation

A. While dietary intake is important, especially regarding sodium and fluid balance, it is not the highest priority compared to monitoring blood pressure.

B. Monitoring the client's blood pressure is essential to evaluate the effectiveness of the prescribed antihypertensive medications and to ensure the client is within the target range for managing her hypertension.

C. Weighing the client is important for monitoring fluid retention, especially with hydrochlorothiazide, but it is secondary to direct blood pressure monitoring.

D. Monitoring the respiratory rate is generally less critical in this scenario unless there are specific concerns related to medication side effects or respiratory conditions.

A. They are under a scheduled drug classification. B. They are ineffective in treating depression or anxiety disorders. C. They can cause gastrointestinal (GI) bleeding and esophageal varices. D. They may cause dangerous interactions with some foods and drugs.

Correct Answer is D

Explanation

A. While MAOIs may have some regulatory considerations, they are not classified under a scheduled drug classification like controlled substances.

B. MAOIs are effective in treating depression and anxiety disorders, which is not the reason for their limited use.

C. Although MAOIs can have some side effects, they are more notably associated with dietary and drug interactions rather than causing GI bleeding or esophageal varices.

D. MAOIs can cause dangerous interactions with foods that contain tyramine (like aged cheeses and fermented products) and certain medications, leading to hypertensive crises, making their use cautious and limiting in clinical practice.

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A patient receiving heparin therapy develops bruising and bleeding gums. What should the nurse suspect and what is the appropriate action?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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