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 A

Explanation

Rationale:

A. Elevated Troponins indicate myocardial injury or infarction.

B. Elevated Creatine kinase (CK) is an enzyme found in skeletal muscle, brain, and myocardium. Elevated levels can indicate muscle damage.

C. Elevated Hemoglobin is not specific to cardiac injury.

D. Elevated B-type Natriuretic peptide (BNP) is used in the diagnosis and management of heart failure.

A. The client experiences sudden weakness of one arm and leg B. The client's ECG tracing shows irregular heart rate without P waves. C. The client's urine output is cloudy and odorous. D. The client has an aPTT of 80 seconds.

Correct Answer is A

Explanation

Rationale:

A. Sudden weakness of one arm and leg may indicate a stroke, which is a potential complication of atrial fibrillation.

B. An irregular heart rate without P waves is characteristic of atrial fibrillation and is expected.

C. Cloudy and odorous urine may indicate a urinary tract infection but is not the priority in this case.

D. An aPTT of 80 seconds is within the therapeutic range for heparin therapy.

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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

A nurse is caring for a client with a possible acute myocardial infarction (AMI). The electrocardiogram (ECG) shows no ST segment elevations or depression. The nurse is aware that an elevation of which lab result will determine if there has been cardiac injury?

Correct Answer is A

Explanation

A nurse is caring for a client diagnosed with atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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Identify the following Cardiac Rhythm:

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A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

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