After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Obtain a soft bristle toothbrush for client.

Provide a PRN nonsteroidal anti-inflammatory (NSAID) for gum discomfort.

Review most recent coagulation lab values.

Report findings to healthcare provider.

Complete a medication variance report.

Answer and Explanation

Correct Answer : A,C,D

A) Obtain a soft bristle toothbrush for the client:
This is an appropriate action because bleeding and tender gums can indicate oral bleeding, which may be exacerbated by the use of a standard toothbrush. Switching to a soft bristle toothbrush can help minimize trauma to the gums and reduce bleeding.

B) Provide a PRN nonsteroidal anti-inflammatory drug (NSAID) for gum discomfort:
Administering NSAIDs in this situation is not recommended. NSAIDs can further increase the risk of bleeding due to their antiplatelet effects. Therefore, providing an NSAID could exacerbate the client’s bleeding symptoms.

C) Review most recent coagulation lab values:
This is a crucial action to assess the client’s coagulation status and determine if the bleeding and bruising are related to anticoagulant therapy. Reviewing coagulation lab values, such as prothrombin time (PT) and international normalized ratio (INR), can provide important information about the client’s clotting function and guide further management.

D) Report findings to the healthcare provider:
This is essential to ensure timely evaluation and management of the client’s symptoms. Bleeding and bruising after anticoagulant therapy may indicate an increased risk of bleeding complications, and the healthcare provider needs to be informed promptly for further assessment and possible adjustment of the anticoagulant regimen.

E) Complete a medication variance report:
While documenting the client’s symptoms and actions taken is important for quality assurance and tracking adverse events, completing a medication variance report may not be the immediate priority in this situation. The focus should be on assessing the client’s condition, managing symptoms, and communicating with the healthcare provider for appropriate intervention

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Correct Answer is D

Explanation

A) Keep an oral liquid or glucose source available:
While it's essential to have a readily available source of glucose in case of hypoglycemia, ensuring consistency in meal timing is more critical for managing blood sugar levels in clients receiving insulin lispro. However, having a glucose source available is still important as a precautionary measure.

B) Check blood glucose levels every six hours:
Frequent monitoring of blood glucose levels is essential in managing diabetes, but checking levels every six hours may not be necessary for all clients. The frequency of blood glucose monitoring should be individualized based on factors such as the client's overall glycemic control, insulin regimen, meal timing, and activity level.

C) Assess for hypoglycemia between meals:
While assessing for hypoglycemia is important, especially in clients receiving insulin therapy, ensuring consistent meal timing is a more proactive measure to prevent hypoglycemia. Clients should ideally consume meals or snacks containing carbohydrates around the same time they administer rapid-acting insulins like insulin lispro to prevent blood sugar fluctuations.

D) Provide meals at the same time this insulin is given:
This is the correct intervention. Insulin lispro is a rapid-acting insulin that is typically administered just before meals to control postprandial blood sugar levels effectively. Providing meals at consistent times relative to insulin administration helps synchronize the peak action of the insulin with the rise in blood glucose that occurs after eating, minimizing the risk of hypoglycemia and hyperglycemia.

A. Serum ammonia level of 30 pg/dl (17.62 μmol /dL). B. Serum glucose level of 120 mg/dL (6.7 mmol/L). C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L). D. Hemoglobin level of 13.5 g/dL (135 g/L).

Correct Answer is C

Explanation

A) Serum ammonia level of 30 pg/dl (17.62 μmol /dL): Serum ammonia level is not directly affected by sodium polystyrene sulfonate administration. Ammonia levels are typically related to liver function and are not relevant in assessing the effectiveness of this medication for hyperkalemia.
B) Serum glucose level of 120 mg/dL (6.7 mmol/L): Serum glucose level is unrelated to the action of sodium polystyrene sulfonate. While hyperkalemia can sometimes lead to glucose metabolism abnormalities, the glucose level alone does not provide information about the medication's effectiveness.
C) Serum potassium level of 3.8 mEq/L (3.8 mmol/L): Sodium polystyrene sulfonate, also known as Kayexalate, is a medication used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium excretion through feces. A decrease in serum potassium level within the normal range indicates that the medication has been effective in lowering potassium levels, which is the intended therapeutic outcome in the context of treating hyperkalemia associated with acute kidney injury (AKI).
D) Hemoglobin level of 13.5 g/dL (135 g/L): Hemoglobin level is unrelated to the action of sodium polystyrene sulfonate. It reflects the oxygen-carrying capacity of red blood cells and is not directly influenced by potassium-lowering medications.

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After receiving the third dose of a new oral anticoagulant prescription, an older client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement for a client with type 2 diabetes mellitus (DM) who is receiving insulin lispro?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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