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?

COPD

Thalassemia

Thrombocytopenia

Rheumatoid arthritis

Answer and Explanation

The Correct Answer is C

Choice A Reason:

COPD (Chronic Obstructive Pulmonary Disease) - While COPD might influence the choice of anaesthesia and perioperative management, it is not a direct contraindication to heparin.

Choice B Reason:

Thalassemia - Thalassemia is a genetic blood disorder that affects haemoglobin production and the structure of red blood cells. It does not directly impact the ability to receive heparin.

Choice C Reason:

Thrombocytopenia. Thrombocytopenia, which is a low platelet count, is a contraindication to receiving heparin, an anticoagulant. Heparin works by preventing the formation of blood clots, but if a person has a low platelet count, their ability to form blood clots is already compromised. Administering heparin in this situation could increase the risk of bleeding and further reduce platelet count.

Choice D Reason:

Rheumatoid arthritis - Rheumatoid arthritis is an autoimmune condition affecting joints. It is not a contraindication to heparin use, but the client's overall health and medications should be considered when planning surgery and anticoagulant therapy.

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Correct Answer is C

Explanation

Choice A Reason:

Repositioning the client's left arm is incorrect. Repositioning the arm might help prevent kinks or occlusions in the tubing, but addressing the tubing connections comes first.

Choice B Reason:

Checking the IV site for redness is incorrect. Checking for redness is important to assess for signs of infection or inflammation, but it can wait until after addressing the tubing issue.

Choice C Reason:

Ensuring the tubing connections are secure is correct. When the infusion pump alarms, the first step is to ensure that the tubing connections are secure. A loose or disconnected tubing can lead to interrupted or inadequate infusion, which could affect the client's treatment and well-being. By checking and securing the tubing connections, the nurse can address any immediate issues related to the alarm.

Choice D Reason:

Flushing the IV catheter is incorrect - Flushing the catheter might be necessary if there are blockages or if medications need to be administered, but addressing the tubing connections is the immediate priority when the infusion pump alarms.

A. Place the client in a protective environment. B. Obtain a stool specimen with gloves. C. Clean surfaces with chlorhexidine. D. Wash hands with alcohol-based hand rub

Correct Answer is B

Explanation

Choice A Reason:

Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.

Choice B Reason:

Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.

Choice C Reason:

Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.

Choice D Reason:

Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is B

Explanation

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