A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

Client develops petechiae on the arms, legs, and abdomen.

Health care provider orders Coumadin 2.5 mg P.O. to begin today.

Client develops slight ecchymosis at the venipuncture site.

Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds.

Answer and Explanation

The Correct Answer is D

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

A. Complete Heart Block B. Sinus Tachycardia C. Ventricular Tachycardia D. Idioventricular Rhythm

Correct Answer is C

Explanation

A. Complete Heart Block: Complete heart block (third-degree AV block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently, resulting in a very slow ventricular rate. This rhythm is characterized by regular P waves that have no relation to the QRS complexes.

B. Sinus Tachycardia: Sinus tachycardia is a rhythm originating from the sinoatrial node with a heart rate typically between 100-150 beats per minute. The rhythm is regular, and the P waves precede each QRS complex consistently.

C. Ventricular Tachycardia: Ventricular tachycardia is a fast heart rhythm that originates from the ventricles. It is characterized by wide and abnormal QRS complexes with a rate usually between 150-250 beats per minute. There may be no visible P waves, and if present, they are not associated with the QRS complexes.

D. Idioventricular Rhythm: Idioventricular rhythm is a slow rhythm originating from the ventricles with a heart rate usually between 20-40 beats per minute. It has wide and abnormal QRS complexes and no visible P waves.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Identify the following Cardiac Rhythm:

Correct Answer is C

Explanation

A nurse is caring for a client newly diagnosed with systemic lupus erythematosus (SLE). The nurse should recognize that which statement made by the client indicates the need for further teaching about the course and management of SLE?

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

A nurse is educating a client who was diagnosed with left testicular cancer and is scheduled for an orchiectomy. Which statement made by the client would require further teaching?

A nurse is caring for a client who is taking furosemide (Lasix) daily to treat heart failure. The nurse recognizes that the client is at risk for which electrolyte imbalance?

A nurse is caring for a client who is receiving hospice care in the home. The family asks, "how will we know when death is near?" The nurse should inform the family that which of the following signs indicates that death is approaching? (Select all that apply.)

A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)