Patient Data

For each nursing action, click to indicate whether the action is a therapeutic communication or a nontherapeutic communication. Each row must have only one response option selected.

A. Elevating the feet if swelling occurs is incorrect because while it may help with edema from conditions such as heart failure or venous insufficiency, it is not related to the primary safety concern with dabigatran, which is the risk of bleeding.

B. Reporting unusual bruising or bleeding is correct. Dabigatran etexilate is a direct thrombin inhibitor used as an anticoagulant to prevent stroke in clients with atrial fibrillation. Because it reduces blood clotting, there is a high risk of bleeding, including easy bruising, nosebleeds, bleeding gums, blood in urine or stool, prolonged bleeding from cuts, or severe headaches and abdominal pain that could indicate internal bleeding. Teaching clients to promptly recognize and report these signs is critical for preventing serious complications and ensuring patient safety.

C. Monitoring blood pressure regularly is incorrect. Although blood pressure management is important for overall cardiovascular health, it does not address the main risk associated with dabigatran, which is bleeding. Regular blood pressure checks alone would not prevent or detect anticoagulant-related complications.

D. Checking the pulse rate every day is incorrect. While monitoring pulse can help track atrial fibrillation and assess heart rhythm, it does not reduce the risk of bleeding or detect anticoagulant-related adverse effects. Prioritizing pulse checks over bleeding recognition would not ensure patient safety.

A. Administering a prescribed albuterol inhaler may be appropriate if the client is experiencing bronchospasm or increased airway resistance. However, before giving any medication, the nurse must report and clarify the low oxygen saturation with the healthcare provider, as supplemental oxygen or other interventions may need adjustment.

B. Assessing lung sounds for signs of infection is important for ongoing evaluation, but this is not the immediate priority in a client who is currently hypoxic. Immediate attention to oxygenation takes precedence.

C. Encouraging the client to initiate a smoking cessation program is important for long-term management of emphysema, but it does not address the current acute hypoxemia.

D. Notifying the healthcare provider of the low pulse oximetry value is the most important action. A pulse oximetry of 88% in a client receiving supplemental oxygen indicates hypoxemia and may require prompt intervention, such as adjusting oxygen flow, administering bronchodilators, or further evaluation for complications like infection or exacerbation of chronic obstructive pulmonary disease (COPD). Immediate reporting ensures timely assessment and treatment to prevent respiratory deterioration.