A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

Thalassemia

Rheumatoid arthritis

Thrombocytopenia

COPD

Answer and Explanation

The Correct Answer is C

A. Thalassemia: A genetic blood disorder affecting hemoglobin production. While patients with severe anemia may have an increased bleeding risk, thalassemia itself is not a contraindication to heparin. Caution is needed if the patient has splenomegaly or significant anemia.

B. Rheumatoid arthritis: An autoimmune condition that can increase bleeding risk due to chronic inflammation and medication use, such as NSAIDs or corticosteroids. However, heparin is not contraindicated unless there is an associated bleeding disorder or severe thrombocytopenia.

C. Thrombocytopenia: A condition characterized by a low platelet count, significantly increasing the risk of bleeding. Heparin use can worsen this condition, especially in cases of heparin-induced thrombocytopenia (HIT), which can lead to both bleeding and thrombosis.

D. COPD: A chronic lung disease that does not directly contraindicate heparin therapy. While COPD patients may be at risk for deep vein thrombosis due to immobility, heparin remains a standard prophylactic treatment unless there are other bleeding risks.

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Correct Answer is C

Explanation

A. Instruct the client to report bleeding: While important, assessing for bleeding is not the immediate priority. Minor blood-tinged sputum can be expected, but significant bleeding should be reported. Ensuring airway protection comes first.

B. Inform the client they might experience a low-grade fever: A mild fever may occur within the first 24 hours after bronchoscopy due to irritation, but addressing airway safety and aspiration risk takes precedence.

C. Check the client's gag reflex: The gag reflex must return before offering oral intake to prevent aspiration. The local anesthetic used for the procedure can suppress the reflex, increasing the risk of aspiration if the client drinks or eats too soon.

D. Provide the client with sips of water: Fluids should not be given until the gag reflex has returned. Providing water too soon could result in aspiration, leading to complications such as pneumonia.

A. Discontinue opioids before trying nonpharmacological methods of pain relief. B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus. C. Use imagery with clients who have difficulty with focus and concentration. D. Distraction changes the client's perception of pain, but it does not affect the cause.

Correct Answer is D

Explanation

A. Discontinue opioids before trying nonpharmacological methods of pain relief: Nonpharmacological interventions can be used alongside opioids to enhance pain relief. Abruptly discontinuing opioids can lead to withdrawal symptoms and inadequate pain control.

B. Pain relief from the use of heat and cold continues for several hours after removal of the stimulus: While heat and cold therapy can provide temporary relief, their effects typically last for a short duration, usually around 15 to 30 minutes after removal.

C. Use imagery with clients who have difficulty with focus and concentration: Guided imagery requires cognitive focus and the ability to concentrate. Clients with impaired attention may struggle to benefit from this technique.

D. Distraction changes the client's perception of pain, but it does not affect the cause: Distraction techniques, such as music or conversation, help shift the client's attention away from pain, altering perception but not addressing the underlying pathology.

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A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

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