A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Review last partial thromboplastin time (PTT) results.

Auscultate bowel sounds in all quadrants.

Monitor stools for presence of blood.

Prepare to administer warfarin.

Assess characteristics of pain.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason: Reviewing the last PTT results is important to ensure that the heparin therapy is within the therapeutic range and to assess for potential over-anticoagulation.

Choice B reason: Auscultating bowel sounds in all quadrants helps determine if there is any bowel obstruction or ileus, which can be associated with abdominal pain.

Choice C reason: Monitoring stools for the presence of blood is essential to identify gastrointestinal bleeding, which can present as tarry, black stools.

Choice D reason: Preparing to administer warfarin is not appropriate in the acute management of potential gastrointestinal bleeding and should be done based on the healthcare provider's instructions.

Choice E reason: Assessing the characteristics of pain is important to better understand the cause of abdominal pain and guide further management.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Oatmeal is high in fiber and helps soften stools, making it a good option for someone with hemorrhoids.

Choice B reason: Bacon slices are not high in fiber and are not recommended.

Choice C reason: Raisin bran muffins are high in fiber and beneficial for managing hemorrhoids.

Choice D reason: Raspberries are high in fiber and are a good choice for a high-fiber diet.

Choice E reason: Scrambled eggs do not contain fiber and are not particularly beneficial for increasing fiber intake.

A. Place an indwelling urinary catheter and institute strict intake and output measurements. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.

Correct Answer is C

Explanation

Choice A reason: Placing an indwelling urinary catheter and instituting strict intake and output measurements can be done later if needed, but addressing the chest pain is the priority.

Choice B reason: Securing consent for coronary angiography and intervention is important but should be done after addressing the immediate chest pain and potential myocardial infarction.

Choice C reason: Administering aspirin is crucial as it acts as an antiplatelet agent, helping to reduce the risk of further clot formation and improving outcomes in the setting of acute coronary syndrome.

Choice D reason: Evaluating extremities for perfusion is important but secondary to administering aspirin in this acute situation.

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A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

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