Nokea
A client is receiving a heparin infusion. The nurse should check the needle site for the heparin infusion for signs of which of the following? Select all that apply.
- A. Inflammation
- B. Pain
- C. Tenderness
- D. Clot formation
- E. Itching
Correct Answer: A,B,C
Rationale: The nurse inspects the needle site for signs of inflammation, pain, and tenderness along the pathway of the vein. If these occur the infusion is discontinued and restarted in another vein.
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A client is being discharged on warfarin therapy. Which of the following would the nurse include in the teaching plan for the client? Select all that apply.
- A. Be consistent with your intake of foods containing vitamin K.
- B. Do not change brands of warfarin without consulting the physician.
- C. Take the drug at the same time every evening.
- D. Do not take or stop taking other medications except on the advice of the physician.
- E. Inform the dentist of therapy with warfarin prior to any treatment or procedure.
Correct Answer: A,B,C,D,E
Rationale: Instructions would include being consistent with intake of foods containing vitamin K, not changing brands of the drug, taking the drug at the same time each evening, not taking or stopping other medications, and informing the dentist about the use of warfarin.
A client is receiving heparin by continuous IV infusion. Which of the following would be most appropriate for the nurse to do?
- A. Perform a complete blood count.
- B. Perform baseline PT/INR.
- C. Perform APTT test 4 to 6 hours after injection.
- D. Perform blood coagulation tests every 4 hours.
Correct Answer: D
Rationale: The nurse should perform blood coagulation tests every 4 hours for the client receiving heparin by continuous IV infusion.
The nurse instructs a client receiving warfarin about the importance of consistent intake of dietary vitamin K to decrease fluctuations in PT/INR. The nurse determines that the client understands the instructions when he identifies which foods as containing vitamin K? Select all that apply.
- A. Broccoli
- B. Cauliflower
- C. Fish
- D. Yogurt
- E. Chicken
Correct Answer: A,B,C,D
Rationale: Foods high in vitamin K include leafy green vegetables, beans, broccoli, cabbage, cauliflower, cheese, fish, and yogurt.
A client is experiencing an overdosage of heparin. The nurse would expect to administer which of the following?
- A. Vitamin K1
- B. Protamine
- C. Ticlopidine
- D. Tenecteplase
Correct Answer: B
Rationale: Heparin overdosage is treated with protamine, which neutralizes heparin's anticoagulant effects.
A client is receiving streptokinase. The nurse understands that which of the following would occur? Select all that apply.
- A. Breakdown of existing thrombi
- B. Reopening of occluded blood vessels
- C. Prevention of tissue necrosis
- D. Decreased risk of internal bleeding
- E. Prevention of formation of a thrombus
Correct Answer: A,B,C
Rationale: Streptokinase is a thrombolytic drug. Thrombolytic drugs break down existing thrombi, reopen blood vessels after occlusion, and prevent tissue necrosis.