A nurse is caring for a female client who has deep-vein thrombosis (DVT) and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb)

Exhibits

Using the client information provided, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.)

 

Rationale:
A. The stool will have a tarry color: Tarry stools typically indicate the presence of digested blood from upper gastrointestinal bleeding. This is not expected after an ileostomy, which involves the small intestine, not the upper GI tract.

B. The stool will have a high volume of liquid: After a colectomy with ileostomy placement, stool bypasses the colon, where most water reabsorption occurs. As a result, the output from an ileostomy is typically frequent and liquid or semi-liquid in consistency.

C. The stool will be solid and well-formed: Solid, well-formed stools are characteristic of a functioning colon. Because the colon is removed in a colectomy with ileostomy, stool will not be solid due to the lack of water absorption.

D. The stool will appear bloody with clots: Bloody stools with clots suggest active bleeding, which is not expected in normal postoperative ileostomy output. This would be an abnormal finding and should be reported immediately.

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.