The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
Notify the healthcare provider.
Monitor for signs of bleeding.
Complete an adverse occurrence report.
Obtain blood for coagulation studies.
The Correct Answer is A
Choice A Reason: This is the correct answer because the nurse should immediately inform the healthcare provider of the medication error and the client's condition. The healthcare provider may order antidotes, such as protamine sulfate for heparin and vitamin K for warfarin, to reverse the anticoagulant effects and prevent bleeding complications.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason: Obtaining blood for coagulation studies is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should obtain blood
samples for coagulation studies, such as prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT), after notifying the healthcare provider and following their orders. The results of these tests can help determine the extent of anticoagulation and guide further therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.
Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.
Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.
Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.
Correct Answer is D
Explanation
Choice A Reason: A subtotal thyroidectomy is a major surgery that involves the removal of part of the thyroid gland. The client may have complications such as bleeding, infection, hypocalcemia, or vocal cord damage. The client also needs close monitoring of vital signs, blood transfusion, and airway patency. This client is not stable enough to be transferred to a general unit.
Choice B Reason: A combined partial and full-thickness burn is a serious injury that involves damage to the epidermis, dermis, and underlying tissues. The client may have complications such as infection, fluid loss, hypovolemia, shock, or respiratory distress. The client also needs wound care, pain management, fluid replacement, and oxygen therapy. This client is not stable enough to be transferred to a general unit.
Choice C Reason: A renal transplant is a major surgery that involves the replacement of a diseased kidney with a healthy one from a donor. The client may have complications such as rejection, infection, bleeding, thrombosis, or urinary obstruction. The client also needs immunosuppressive therapy, anti-infective therapy, fluid and electrolyte balance, and pain management. This client is not stable enough to be transferred to a general unit.
Choice D Reason: Nephrotic syndrome is a kidney disorder that causes excessive protein loss in the urine, leading to low serum protein levels and edema. The client may have complications such as infection, thromboembolism, or malnutrition. The client needs diuretic therapy, protein replacement, dietary modification, and infection prevention. This client is relatively stable and can be transferred to a general unit.
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