A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?
The patient’s PTT is 70 seconds (control 25-40).
The patient develops ecchymosis at the venipuncture site.
The patient develops hematuria.
There is an order for Coumadin 2.5 mg to start today.
Correct Answer : A,C,D
Choice A rationale
A PTT of 70 seconds (control 25-40) indicates that the patient’s blood is taking longer than normal to clot, which could increase the risk of bleeding. This could be a sign of excessive anticoagulation from the Heparin infusion.
Choice B rationale
Ecchymosis at the venipuncture site could be a sign of bleeding under the skin, which could indicate that the patient is receiving too much Heparin.
Choice C rationale
Hematuria, or blood in the urine, could be a sign of bleeding in the urinary tract, which could be a side effect of Heparin therapy.
Choice D rationale
If there is an order for Coumadin 2.5 mg to start today, the healthcare provider should be notified. Coumadin and Heparin are both anticoagulants, and using them together could increase the risk of bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Culturally incompetent caregivers can be a significant barrier to appropriate communication with clients. Cultural competence involves understanding and respecting the cultural differences and preferences of clients, which can greatly influence how they perceive and respond to healthcare communication.
Choice B rationale
Proper training in healthcare communication is not a barrier, but rather a facilitator of appropriate communication with clients. It equips healthcare professionals with the necessary skills and knowledge to communicate effectively with clients.
Choice C rationale
Excellent health literacy is not a barrier, but rather a facilitator of appropriate communication with clients. Clients with excellent health literacy are better able to understand and engage in healthcare communication.
Choice D rationale
Implicit bias can be a significant barrier to appropriate communication with clients. It refers to the unconscious attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.
Choice E rationale
Lack of diversity can be a significant barrier to appropriate communication with clients. Diversity in the healthcare workforce can enhance the understanding of the cultural and social needs of diverse client populations, thereby improving communication.
Correct Answer is D
Explanation
Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.
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