A patient has been taking heparin for three days and has developed hematuria. The most appropriate action for the nurse is to:

Insert a urinary catheter to determine the residual urine

Hold the next dose of heparin and contact the physician

Instruct the patient to drink adequate amounts of fluid

Administer an additional dose of heparin subcutaneously

Answer and Explanation

The Correct Answer is B

A. Insert a urinary catheter to determine the residual urine. Inserting a urinary catheter may be necessary to accurately measure urinary output and assess for signs of urinary retention. However, the presence of hematuria suggests a potential bleeding complication related to heparin therapy. While monitoring urinary output is important, inserting a urinary catheter should not be the first action taken in response to hematuria. Other interventions to address the bleeding should be prioritized.

B. Hold the next dose of heparin and contact the physician. This is the correct answer. Hematuria can be a sign of a bleeding complication, which is a known side effect of heparin therapy. Holding the next dose of heparin is appropriate to prevent further bleeding, and contacting the physician ensures prompt evaluation and appropriate management of the patient's condition. The physician may decide to adjust the dose of heparin, temporarily discontinue it, or order further investigations to determine the cause of the hematuria.

C. Instruct the patient to drink adequate amounts of fluid. While maintaining hydration is important for overall health, instructing the patient to drink fluids would not directly address the underlying cause of hematuria, which may be related to a bleeding complication from heparin therapy. Holding the next dose of heparin and contacting the physician are more appropriate actions in response to hematuria.

D. Administer an additional dose of heparin subcutaneously. Administering additional heparin would exacerbate the bleeding risk and is contraindicated in the presence of hematuria. It is important to withhold further doses of heparin and seek medical guidance to address the bleeding complication.

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Correct Answer is D

Explanation

White Blood Cells (WBCs): WBCs are part of the immune system and play a role in fighting infections. However, they are not directly involved in hemostasis or clot formation.

Antibodies: Antibodies are proteins produced by the immune system to recognize and neutralize foreign substances (antigens). They do not directly participate in clot formation.

Red Blood Cells (RBCs): RBCs carry oxygen and carbon dioxide but are not directly involved in clotting. They do not adhere to the vessel wall during hemostasis.

Platelets: Platelets are small cell fragments in the blood. They clump together (aggregate) at the site of injury to form a temporary plug (platelet plug). Platelets adhere to the injured vessel wall and release chemicals that initiate clotting.

A. Have suction equipment at the bedside. B. Monitor the client for black, tarry stools. C. Administer the medication with each meal. D. Initiate contact precautions.

Correct Answer is B

Explanation

A. Have suction equipment at the bedside. Clopidogrel is an antiplatelet medication that inhibits blood clot formation. While it does not typically increase the risk of bleeding to the extent that requires constant suctioning, it's prudent to have suction equipment readily available for any patient who may be at risk of bleeding due to their underlying condition or concurrent medications. However, the administration of clopidogrel alone does not necessitate the need for constant suctioning.

B. Monitor the client for black, tarry stools. This is the correct answer. Clopidogrel, like other antiplatelet medications, increases the risk of bleeding, including gastrointestinal bleeding. Black, tarry stools can indicate gastrointestinal bleeding, which can be a serious complication of clopidogrel therapy. Therefore, monitoring for this symptom is essential for early detection of potential bleeding complications.

C. Administer the medication with each meal. Clopidogrel can be administered with or without food, as it is not significantly affected by food intake. However, there is no specific recommendation to administer it with meals. The timing of administration may vary based on the prescriber's instructions or patient preferences, but it does not need to be consistently administered with meals.

D. Initiate contact precautions. Clopidogrel therapy does not require contact precautions. Contact precautions are typically implemented for patients with contagious infections that spread via direct or indirect contact. Clopidogrel does not pose a risk of transmission to others and does not warrant contact precautions.

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A patient has been taking heparin for three days and has developed hematuria. The most appropriate action for the nurse is to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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