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. Atropine is used to treat bradycardia and is not indicated for pulmonary embolism. It would not be the first choice in managing this condition.

B. Heparin is an anticoagulant that helps prevent further clot formation in the case of a pulmonary embolism. It is typically administered to stabilize the patient and reduce the risk of further embolic events.

C. Dexamethasone is a corticosteroid used to treat inflammation and is not typically used to treat pulmonary embolism. It is not the first-line treatment for this condition.

D. Furosemide is a diuretic used to manage fluid retention and is not directly indicated for pulmonary embolism. It may be used in cases of heart failure or pulmonary edema, but it is not the primary treatment for a pulmonary embolism.

A. Compartment syndrome B. Hypovolemic shock C. Fat embolism syndrome D. Venous thromboembolism

Correct Answer is C

Explanation

A. Compartment syndrome is a complication of fractures, particularly when swelling within a closed muscle compartment compromises circulation. However, it typically presents with severe localized pain, paresthesia, pallor, and pulselessness, not systemic symptoms like shortness of breath and chest pain.

B. Hypovolemic shock can occur due to significant blood loss from fractures, but it is characterized by hypotension, tachycardia, and altered mental status rather than chest pain and shortness of breath.

C. Fat embolism syndrome (FES) is a serious complication of long bone fractures. Fat globules from the bone marrow can enter the bloodstream and lodge in the lungs, causing respiratory distress, chest pain, hypoxemia, and sometimes a petechial rash. The timing (24 hours post-injury) and symptoms suggest FES.

D. Venous thromboembolism (VTE) can cause similar symptoms, but it typically develops later than 24 hours post-injury and is less common immediately after fractures compared to FES.

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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 nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Correct Answer is B

Explanation

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

Correct Answer is C

Explanation

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