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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Continuous bubbling within the water seal chamber indicates an air leak in the system, which is not a sign of proper chest tube functioning. The nurse should investigate and address any air leaks promptly.
B. Fluctuation of the fluid level within the water seal chamber, also known as tidaling, indicates that the chest tube is functioning properly. Tidaling reflects changes in intrapleural pressure during respiration and confirms that the system is intact.
C. Absence of fluid in the drainage tubing is not an indicator of proper functioning. Depending on the client’s condition, there may or may not be fluid in the tubing. However, the system should always be assessed for patency and appropriate drainage.
D. Equal amounts of fluid drainage in each collection chamber are not expected or required. The amount of drainage depends on the client’s condition and does not indicate the functionality of the chest tube system.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
A. Diarrhea: Not relevant to the client's condition of impaired mobility and recent hip fracture.
B. Hypocalcemia: Not directly related to the client's current condition and symptoms.
C. Pulmonary embolism: The client is at risk due to limited mobility and signs of deep vein thrombosis.
D. Deep vein thrombosis: The client has symptoms such as a warm, reddened area on the calf, indicating a potential DVT.
E. Hypertension: The client's blood pressure is within normal limits, so this is not a primary concern.
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