A nurse is caring for a client who is receiving an IV infusion of heparin. Which of the following findings should indicate to the nurse the client is at risk for hemorrhage? (Select all that apply.)

Thrombocytopenia.

Neutropenia.

Hypokalemia.

Fever.

Hyperglycemia.

Dark stools.

Answer and Explanation

Correct Answer : A,F

Choice A rationale
Thrombocytopenia, a low platelet count, increases the risk of bleeding and hemorrhage when receiving heparin.
Choice B rationale
Neutropenia, a low white blood cell count, does not directly increase the risk of hemorrhage. It is more related to infection risk.
Choice C rationale
Hypokalemia, low potassium levels, does not directly indicate a risk for hemorrhage. It can cause other complications but not specifically bleeding.
Choice D rationale
Fever is not a direct indicator of hemorrhage risk. It may indicate infection or other inflammatory processes.
Choice E rationale
Hyperglycemia, high blood sugar levels, does not indicate a risk for hemorrhage. It is more related to diabetes management.
Choice F rationale
Dark stools can indicate gastrointestinal bleeding, which is a sign of hemorrhage.

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Correct Answer is C

Explanation

Choice A rationale
A standing prescription is an order that applies to all patients who meet certain criteria and is not specific to a single administration. It is used for routine treatments and does not apply to a one-time pre-transfusion medication.
Choice B rationale
A stat prescription is an urgent order that requires immediate administration, typically within minutes. It is used for emergency situations and does not apply to a pre-transfusion medication given one hour before the procedure.
Choice C rationale
A single prescription is a one-time order for a specific medication to be given at a specific time. In this case, diphenhydramine 50 mg by mouth once, one hour prior to transfusion, fits the definition of a single prescription.
Choice D rationale
A PRN (pro re nata) prescription is an order for medication to be given as needed based on the patient’s condition. It is not applicable to a scheduled pre-transfusion medication. .

A. Muscle weakness. B. Hyperactive bowel sounds. C. Tingling of fingers. D. Peaked T waves. E. Fatigue.

Correct Answer is ["A","E"]

Explanation

Choice A rationale
Muscle weakness is a common symptom of hypokalemia due to decreased potassium levels affecting muscle function.
Choice E rationale
Fatigue is another symptom of hypokalemia as low potassium levels can impair cellular function and energy production.

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A nurse is caring for a client who is receiving an IV infusion of heparin. Which of the following findings should indicate to the nurse the client is at risk for hemorrhage? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires a transfusion of one unit of packed RBCs. The nurse receives the following prescription: “Diphenhydramine 50 mg by mouth once, one hour prior to transfusion.”. The nurse should identify this as which of the following types of prescription?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking a glucocorticoid. Which of the following findings should indicate to the nurse the client is experiencing hypokalemia? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

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