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 C

Explanation

A. Obtaining an arterial blood gas and ordering a chest x-ray may be necessary to evaluate the client further, but the nurse must first assess the client to determine the presence of clinical signs of fat embolism syndrome (FES), such as respiratory distress or neurological changes.

B. Keeping the client on strict bed rest may help reduce the risk of further complications, but it is not the first priority. Immediate assessment of the client’s condition is necessary to identify signs of fat embolism syndrome.

C. Assessing the client for dyspnea and altered mental status is the first priority because these symptoms are early indicators of fat embolism syndrome. Early recognition and intervention are critical in preventing further complications.

D. Contacting the healthcare provider for a ventilation and perfusion scan may be appropriate after assessing the client, but it is not the first action. Immediate assessment is essential to determine the urgency of the situation.

Correct Answer is ["31"]

Explanation

Convert liters to milliliters: 1 liter = 1000 mL
Calculate total infusion time in minutes: 8 hours 60 minutes/hour = 480 minutes
Apply the formula:
- (Total volume in mL Drop factor) / Total infusion time in minutes = Drops/minute
- (1000 mL 15 gtts/mL) / 480 minutes = 31.25 gtts/minute
Round to the nearest whole number: 31 gtts/minute

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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?

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Naxlex Comprehensive Predictor Exams

Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has "fatty globules" floating in the urinal. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

Correct Answer is ["31"]

Explanation

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