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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.

A. Apply warm compresses. B. Complete prescribed antibiotics. C. Avoid smoking. D. Avoid swimming. E. Periorbital edema is a normal finding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Applying warm compresses can help relieve the pain and pressure associated with acute rhinosinusitis by reducing inflammation and promoting sinus drainage.
Choice B rationale
Completing prescribed antibiotics is crucial in treating acute bacterial rhinosinusitis. Antibiotics help eliminate the bacterial infection causing the inflammation and symptoms.
Choice C rationale
Smoking can irritate the nasal passages and exacerbate the symptoms of rhinosinusitis. Avoiding smoking can help reduce inflammation and promote healing.
Choice D rationale
Swimming, especially in chlorinated pools, can irritate the nasal passages and sinuses, potentially worsening the symptoms of rhinosinusitis. It’s recommended to avoid swimming until the condition has resolved.
Choice E rationale
Periorbital edema is not a normal finding and could indicate a complication of rhinosinusitis, such as a spread of the infection. If a client notices this symptom, they should seek medical attention.

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A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed in the Emergency Department with acute respiratory distress syndrome (ARDS). Which of the following actions should a nurse perform first?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with acute rhinosinusitis. Which of the following instructions should the nurse provide to the client? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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