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 B

Explanation

A. Administering supplemental oxygen is appropriate if the low oxygen saturation is confirmed, but the nurse should first verify the accuracy of the reading to avoid unnecessary interventions.

B. Checking the position of the pulse oximeter probe and ensuring it is properly attached is the first step. Faulty probe placement or technical issues can cause inaccurate readings, so confirming the validity of the drop in SpO2 is essential before taking further action.

C. Assessing the client's airway for obstruction is critical if the low SpO2 is verified and no technical issues are found. However, this step follows confirming the accuracy of the pulse oximetry reading.

D. Notifying the healthcare provider is necessary if the drop in SpO2 is confirmed and persists despite initial nursing interventions, but it is not the first action.

A. Chest pain that worsens with deep breathing B. Shortness of breath C. Facial weakness that worsens at night D. Bloody sputum E. Difficulty speaking

Correct Answer is ["A"]

Explanation

A. Chest pain that worsens with deep breathing, also known as pleuritic pain, is a hallmark symptom of pulmonary embolism. It occurs due to inflammation of the pleura caused by the obstruction in the pulmonary vasculature.

B. Shortness of breath is one of the most common and early signs of a pulmonary embolism. It occurs due to reduced oxygenation resulting from blocked blood flow in the lungs.

C. Facial weakness that worsens at night is not a manifestation of pulmonary embolism. This symptom is more commonly associated with neurological conditions such as myasthenia gravis.

D. Bloody sputum, or hemoptysis, is a possible symptom of pulmonary embolism. It results from pulmonary infarction, which occurs when lung tissue is damaged due to reduced blood flow.

E. Difficulty speaking is not typically associated with pulmonary embolism. This symptom may be more indicative of neurological events such as stroke.

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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

During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

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Correct Answer is ["A"]

Explanation

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