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. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.

B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.

C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.

D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.

A. Obtain pulse oximetry every two hours. B. Teach the client how to use the incentive spirometer. C. Instruct the client to practice abdominal breathing. D. Encourage oral fluid intake of 2000 mL/24 hours.

Correct Answer is B

Explanation

A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.

B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.

C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.

D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Correct Answer is D

Explanation

A nurse is caring for a client following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Correct Answer is B

Explanation

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