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.

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Correct Answer is D

Explanation

A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.

B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.

C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.

D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.

A. Health care providers should be told about the diagnosis to deliver safe care. B. Most people in current society would be accepting of the diagnosis. C. Intimate partners should be told so they can protect themselves. D. The diagnosis is reportable to the state health department. E. Secrecy about the diagnosis is the privilege of the client.

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

Explanation

A. Health care providers should be told about the diagnosis to deliver safe care: Health care providers need to know the client's diagnosis to provide appropriate and safe care. This includes administering medications, assessing for opportunistic infections, and implementing preventive measures.

B. Most people in current society would be accepting of the diagnosis: While stigma surrounding HIV/AIDS has decreased over time, disclosure is a personal decision, and not all individuals may be accepting of the diagnosis. Therefore, this statement may not always be accurate.

C. Intimate partners should be told so they can protect themselves: Disclosing the diagnosis to intimate partners is essential for their health and well-being, as it allows them to take necessary precautions to prevent transmission of the virus.

D. The diagnosis is reportable to the state health department: In many jurisdictions, HIV/AIDS diagnoses are reportable to the state health department for surveillance and public health monitoring purposes. This reporting is typically done without disclosing the client's identity.

E. Secrecy about the diagnosis is the privilege of the client: While confidentiality is crucial, it's important to balance it with public health considerations and the well-being of others who may be at risk of infection.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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