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 D

Explanation

Choice A reason: Systemic inflammatory response is more characteristic of rheumatoid arthritis rather than osteoarthritis.

Choice B reason: Infectious process in the synovial fluid suggests septic arthritis, not osteoarthritis.

Choice C reason: Loss of bone mineral density is related to osteoporosis, not specifically to osteoarthritis.

Choice D reason: Osteoarthritis is characterized by the destruction of joint cartilage, leading to pain and stiffness in the affected joints.

A. PO administration of divalproex. B. PO administration of lorazepam. C. IV administration of benztropine. D. IV administration of isotonic crystalloid fluid.

Correct Answer is C

Explanation

Choice A reason: Divalproex is not used for treating acute dystonic reactions.

Choice B reason: Lorazepam can be used for certain types of acute reactions but is not the first line of treatment for dystonic reactions with laryngeal spasm.

Choice C reason: IV administration of benztropine is appropriate for treating acute dystonic reactions, including laryngeal spasm, as it helps to relieve the muscle contractions.

Choice D reason: IV administration of isotonic crystalloid fluid is not a treatment for dystonic reactions but may be used to maintain hydration and electrolyte balance.

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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

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes which pathology as the cause of the symptoms?

Correct Answer is D

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is C

Explanation

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