Based on the nurse's assessment which cues support the decision to provide intervention for the client's pain as the first priority? (Select all that
... [Show More] apply. One, some, or all options may be correct.)
Blood pressure.
Client's reported pain level of 7/10.
History of rheumatoid arthritis.
Recent hip surgery within the last 3 months.
Examination of the client's right lower extremity.
The client is describing the pain in her right leg as severe and concentrated in her foot and ankle. The nurse receives a prescription from the HCP for hydrocodone bitartrate and acetaminophen 5/325 two tabs PO prior to the client's exam. Before initiating the treatment, it is most important for the nurse to implement which interventions? (Select all that apply. One, some, or all options may be correct.)
Perform a focused assessment on the lower right extremity.
Implement a numeric pain assessment on a scale of 1 to 10.
Document a baseline of vital signs including a pulse oximetry.
Use at least two client identifiers before administering the medication.
Which non-pharmacologic nursing interventions will reduce pain related to decreased venous flow? (Select all that apply. One, some, or all options may be correct.)
Elevate the affected leg.
Apply a warm compress.
The nurse must educate the client about the venous ultrasound by distinguishing it from the venography. Which description accurately expresses these diagnostic tests?
If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagonis.
Anticoagulants are the drug of choice for clients with actual DVT and so the HCP prescribed Heparin therapy for the client. Which conclusions regarding Heparin administration are accurate? (Select all that apply. One, some, or all options may be correct.)
Heparin infusion requires laboratory monitoring and dose adjustment.
Heparin is known to cause medical complications even death.
Heparin therapy is administered via intravenous route.
Protamine sulfate is the anecdote for heparin.
When the heparin therapy is initiated, the nurse analyzes which lab value to determine that a therapeutic heparin level has been reached?
APTT 65 seconds, control 35 seconds.
What is the correct IV bolus dose of heparin the nurse should administer? (Enter numerical value only. If rounding is necessary, round to the tenth.) mL ______ Submit
6
Refer to the HCP prescription and calculate the continuous infusion rate for the IV dosage of heparin. _____ units/hr.
1650
The nurse completes preparation of the initial heparin infusion and prior to administering takes which of the following actions? (Select all that apply. One, some, or all options may be correct.)
Assesses client for allergies.
Identifies client with two forms of identification.
Ensure the client's IV access is intact and patent.
Verifies baseline coagulation studies have been drawn.
Initiates two nurses to check calculation accuracy.
At what rate should the IV pump be set to deliver the prescribed rate of infusion? (Enter numerical value only. If rounding is necessary, round to the whole number.) _____ mL/hr
33
During heparin therapy, the client's APTT is monitored every 6 hours and the midnight results were APTT 120 seconds, control 35 seconds.Based on these cues, what action should the nurse expect to initiate?
Decrease and maintain this rate until the next APTT check in 6 hours.
The incoming nurse notices which cue as the cause of observable hematuria in the client's urinary catheter?
The IV pump infusing at a higher rate than prescribed.
Heparin overdose can cause life threatening hemorrhaging, such as nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising. Which of these actions should the nurse take for the client's safety? (Select all that apply. One, some, or all options may be correct.)
Stop the heparin infusion.
Obtain a stat APTT.
Assess vital signs.
Anticipate a prescription of protamine sulfate.
After consulting with the HCP, the nurse is to administer a heparin antagonist. The nurse explains to the client that protamine sulfate is being administered to obtain which expected outcome?
Reduce hematuria.
Another less common complication of heparin therapy is Heparin Induced Thrombocytopenia (HIT). What if the client develops fever and chills? Based on these cues, the nurse recognizes that it is essential to obtain which information first?
Platelet count.
What information is included in an Incident Report? (Select all that apply. One, some, or all options may be correct.)
Person who witnessed event writes report.
Injuries resulting from incident.
Response and corrective measures taken
Review the incident involving the client's IV pump and hematuria. What specific information resulting from this event should be included in the client's incident report? (Select all that apply. One, some, or all options may be correct.)
Day nurse received prescription to decrease Heparin infusion to 30 mL/hour.
Nurse took action and stopped infusion.
Oncoming nurse is named as witness and writes incident report.
Oncoming nurse observes IV pump infusing at 50mL/hour.
HCP contacted and prescribed STAT APTT and protamine sulfate.
What is the legal concern involved in this situation?
Malpractice
The Joint Commission's National Patient Safety Goals (NPSG) encourages clients and families to have an opportunity for input into their plan of care. Which nursing action is the best for increasing client safety, satisfaction, and continuity of care?
Nurse-to-Nurse bedside report.
Which nursing actions are most important for preventing bleeding complications? (Select all that apply. One, some, or all options may be correct.)
Adjust infusion based on APTT results and institutional protocol.
Maintain heparin on a continuous infusion pump.
Monitor platelets daily.
Apply pressure to venipuncture sites.
Which action can be delegated by the nurse to the UAP?
Obtain stool specimen for guaiac.
At the end of the shift, the nurse realizes the UAP has not reported obtaining the stool specimen. The nurse provides privacy before giving criticism and uses which communication approach with the UAP?
"I've noticed that the client's stool specimen was not obtained."
Which of the following instructions should the nurse include in the client's teaching plan? (Select all that apply. One, some, or all options may be correct.)
Teach client to take warfarin as prescribed by HCP.
The client should wear a medic-alert bracelet.
The client should notify all future HCPs that she takes warfarin.
Follow-up with INR monitoring as prescribed by HCP.
The client should also be instructed to avoid which over-the-counter (OTC) products? (Select all that apply. One, some, or all options may be correct.)
Calcium carbonate.
Aspirin, salicylates, ibuprofen and naproxen.
Garlic.
Acetaminophen.
As part of her discharge teaching, the nurse recommends that the client implement several important preventative measures at home. Which interventions are recommended by the nurse? (Select all that apply. One, some, or all options may be correct.)
Inspect the legs and feet daily.
Avoid forcefully blowing your nose.
Shave with an electric instead of a blade razor.
Use a soft-bristle toothbrush and avoid flossing.
The nurse records the following information the day that the client is scheduled for discharge. Calf circumference equal bilaterally. Prothrombin is 12, INR is twice normal. Oxygen saturation level per oximeter is 98%. Based on these findings, which action should the nurse implement?
Continue with discharge teaching. [Show Less]