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The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin.
- B. Check the client's INR prior to beginning Coumadin.
- C. Clarify the order with the health-care provider as soon as possible.
- D. Administer the Coumadin along with the heparin drip as ordered.
Correct Answer: D
Rationale: Heparin and warfarin are often overlapped for 3–5 days in acute DVT until warfarin’s INR is therapeutic (D). Discontinuing heparin (A) is premature, INR (B) is checked later, and clarification (C) is unnecessary.
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Which intervention should the nurse include in the plan of care for a client with pericarditis? Select all that apply.
- A. Monitor for signs of cardiac tamponade.
- B. Administer anti-inflammatory medications.
- C. Encourage deep breathing exercises.
- D. Elevate the head of the bed.
- E. Restrict all physical activity.
- F. Check vital signs every 8 hours.
Correct Answer: A,B,D,E
Rationale: Monitoring for tamponade, administering anti-inflammatories, elevating the bed, and restricting activity manage pericarditis effectively.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
The nurse just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease who has a BP of 170/100.
- B. The client diagnosed with DVT who is complaining of chest pain.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
- D. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.
Correct Answer: B
Rationale: Chest pain in DVT (B) suggests pulmonary embolism, a life-threatening emergency. Hypertension (A) is urgent but less immediate, SpO2 98% (C) is normal, and diarrhea (D) is non-emergent.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.
The nurse is preparing the client for an arteriogram. Which instruction is most important to include?
- A. You will need to lie flat for several hours after the procedure.
- B. You can eat a light meal before the test.
- C. Avoid moving your legs during the procedure.
- D. Take your blood pressure medication as usual.
Correct Answer: A
Rationale: Lying flat post-arteriogram prevents bleeding at the catheter insertion site, typically in the femoral artery.