A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

Petechiae

Slowing pulse rate

Confusion

Pruritus

Answer and Explanation

The Correct Answer is A

Rationale:

A. Petechiae are small, pinpoint red or purple spots on the skin that may indicate bleeding or thrombocytopenia, which can be a side effect of heparin therapy.

B. Slowing pulse rate is not typically associated with heparin therapy.

C. Confusion is not typically associated with heparin therapy.

D. Pruritus (itching) is not typically associated with heparin therapy.

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Correct Answer is C

Explanation

Rationale:

A. This is wrong because the ECG leads show ST segment elevation.

B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.

C. This is correct because of the ST segment elevation.

D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.

A. Suggest that the client use a salt substitute. B. Advise the client to add citrus juices and bananas to her diet. C. Obtain a 12-lead ECG D. Obtain a blood sample for a serum sodium level

Correct Answer is C

Explanation

Rationale:

A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.

B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.

C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.

D. A serum sodium level should be obtained but it is not the priority in this case.

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A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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