After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Obtain a soft bristle toothbrush for client.

Provide a PRN nonsteroidal anti-inflammatory (NSAID) for gum discomfort.

Review most recent coagulation lab values.

Report findings to healthcare provider.

Complete a medication variance report.

Answer and Explanation

Correct Answer : A,C,D

A) Obtain a soft bristle toothbrush for the client:
This is an appropriate action because bleeding and tender gums can indicate oral bleeding, which may be exacerbated by the use of a standard toothbrush. Switching to a soft bristle toothbrush can help minimize trauma to the gums and reduce bleeding.

B) Provide a PRN nonsteroidal anti-inflammatory drug (NSAID) for gum discomfort:
Administering NSAIDs in this situation is not recommended. NSAIDs can further increase the risk of bleeding due to their antiplatelet effects. Therefore, providing an NSAID could exacerbate the client’s bleeding symptoms.

C) Review most recent coagulation lab values:
This is a crucial action to assess the client’s coagulation status and determine if the bleeding and bruising are related to anticoagulant therapy. Reviewing coagulation lab values, such as prothrombin time (PT) and international normalized ratio (INR), can provide important information about the client’s clotting function and guide further management.

D) Report findings to the healthcare provider:
This is essential to ensure timely evaluation and management of the client’s symptoms. Bleeding and bruising after anticoagulant therapy may indicate an increased risk of bleeding complications, and the healthcare provider needs to be informed promptly for further assessment and possible adjustment of the anticoagulant regimen.

E) Complete a medication variance report:
While documenting the client’s symptoms and actions taken is important for quality assurance and tracking adverse events, completing a medication variance report may not be the immediate priority in this situation. The focus should be on assessing the client’s condition, managing symptoms, and communicating with the healthcare provider for appropriate intervention

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Correct Answer is D

Explanation

Answer: D. Antiretroviral medication prevents the transmission of the virus.

Rationale:

A. The viral load can be decreased to an undetectable level:
This statement reflects an accurate understanding of antiretroviral therapy. Effective treatment can reduce the viral load to undetectable levels, which is a key goal of HIV treatment, allowing individuals to live healthier lives and reducing the risk of transmitting the virus to others.

B. HIV infection is not cured by the antiretroviral regimen:
This statement is also accurate. Antiretroviral therapy (ART) effectively manages HIV infection but does not cure it. Patients need to remain on medication for life to control the virus and maintain their health.

C. The medications can decrease acquired AIDS-related complications:
This statement is correct as well. Antiretroviral medications can help manage HIV and prevent the progression to AIDS, thereby reducing the likelihood of complications associated with AIDS, such as opportunistic infections.

D. Antiretroviral medication prevents the transmission of the virus:
This statement requires additional instruction because, while effective antiretroviral therapy can significantly reduce the risk of transmission, it does not entirely prevent it. Patients with an undetectable viral load have a greatly reduced risk of transmitting HIV to sexual partners (often summarized as "U=U" or "Undetectable = Untransmittable"), but it is crucial to understand that there is still a small risk involved. Therefore, additional education is necessary to clarify the need for continued safe practices, such as using condoms, even when on effective therapy.

A. Expresses that they cannot get enough air to breathe. B. Respiratory rate of 7 breaths/minute. C. Bilateral wheezing on auscultation. D. Pulse oximeter reading of 89% on room air.

Correct Answer is B

Explanation

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

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After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client who has been diagnosed with HIV about the antiretroviral medication regimen. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Rationale:

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Correct Answer is B

Explanation

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