A client receiving low molecular weight heparin subcutaneously to prevent DVT following hip replacement surgery reports to the nurse that she observed small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement?

Check the client’s PTT level immediately

Explain this is a result of the medication

Notify the healthcare provider immediately

Assess the client’s blood pressure and heart rate

Answer and Explanation

The Correct Answer is B

A. Checking the client’s PTT level is unnecessary in this situation because low molecular weight heparin (e.g., enoxaparin) does not typically require PTT monitoring. This test is more relevant for clients receiving unfractionated heparin.

B. Small purple hemorrhagic areas (ecchymosis) at the injection sites are a common and expected side effect of low molecular weight heparin. The nurse should explain to the client that this is a normal reaction to the medication and does not indicate a serious issue.

C. Notifying the healthcare provider immediately is not warranted unless the client shows signs of excessive bleeding, such as hematomas, significant bruising, or a drop in blood pressure. The described ecchymosis is a minor and expected side effect.

D. Assessing the client’s blood pressure and heart rate is a reasonable step if there are concerns about significant bleeding or hemodynamic instability. However, in this case, the described symptoms are localized and do not suggest systemic bleeding.

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Correct Answer is A

Explanation

A. Flail chest occurs when multiple ribs are fractured in more than one location, creating a free-floating segment of the chest wall. This segment moves paradoxically during respiration, meaning it moves inward during inspiration and outward during expiration, which impairs effective breathing and oxygenation.

B. Paralysis of the chest wall may occur in conditions like spinal cord injuries but is not the defining characteristic of flail chest.

C. While decreased oxygenation can occur with flail chest due to impaired ventilation, the defining feature is the paradoxical movement of the fractured rib segment.

D. Weakness of the diaphragm can impair lung expansion, but this is characteristic of conditions like diaphragmatic paralysis, not flail chest.

A. The patient inhales and exhales quickly through pursed lips. B. The patient inhales deeply through the nose and exhales quickly through pursed lips. C. The patient inhales deeply through the nose and exhales slowly through pursed lips. D. The patient inhales deeply through pursed lips and exhales quickly through the nose.

Correct Answer is C

Explanation

A. Inhaling and exhaling quickly through pursed lips does not achieve the intended purpose of pursed-lip breathing. This technique is designed to promote slower, controlled breathing to prevent airway collapse and improve oxygen exchange.

B. Exhaling quickly through pursed lips negates the benefits of pursed-lip breathing. The purpose of this technique is to prolong exhalation, reducing air trapping and improving ventilation.

C. Inhaling deeply through the nose and exhaling slowly through pursed lips is the correct technique for pursed-lip breathing. This method helps maintain open airways, reduces dyspnea, and promotes relaxation.

D. Inhaling deeply through pursed lips and exhaling quickly through the nose is not consistent with proper pursed-lip breathing. The inhalation should be through the nose, and exhalation should be slow and controlled through pursed lips.

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A client receiving low molecular weight heparin subcutaneously to prevent DVT following hip replacement surgery reports to the nurse that she observed small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to the respiratory unit with flail chest. The nurse understands that a flail chest is:

Correct Answer is A

Explanation

The nurse teaches a patient with chronic obstructive pulmonary disease (COPD) about pursed-lip breathing (PLB). Which action by the patient would indicate to the nurse that no further teaching is needed?

Correct Answer is C

Explanation

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