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 ["121"]

Explanation

Calculation Steps:

Step 1: Convert weight from pounds to kilograms: 160 pounds ÷ 2.2 = 72.7 kg. Result = 72.7 kg.

Step 2: Calculate the total daily dose: 5 mg/kg/day × 72.7 kg = 363.5 mg/day. Result = 363.5 mg/day.

Step 3: Calculate the dose per administration: 363.5 mg/day ÷ 3 doses/day = 121.2 mg/dose. Result = 121.2 mg/dose.

Step 4: Round to the nearest whole number: 121.2 mg ≈ 121 mg.

Result = 121 mg.

A. Hold urine for at least 10 minutes to dilute bacteria. B. Empty the bladder before and after sexual intercourse. C. Drink large amounts of fluids before bedtime. D. Cleanse the perineal area in a circular motion after voiding.

Correct Answer is B

Explanation

Choice A reason: Holding urine for at least 10 minutes does not dilute bacteria and can actually increase the risk of infection.

Choice B reason: Emptying the bladder before and after sexual intercourse helps flush out bacteria that may have been introduced during intercourse, reducing the risk of UTI.

Choice C reason: Drinking large amounts of fluids before bedtime is not specific to preventing UTIs and may lead to nighttime urination, disrupting sleep.

Choice D reason: Cleansing the perineal area in a circular motion is not the recommended method. The recommended practice is to wipe from front to back to prevent the spread of bacteria from the rectal area to the urethra.

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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 who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["121"]

Explanation

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Correct Answer is B

Explanation

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