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The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement first?
- A. Stay with the client and call the Rapid Response Team (RRT).
- B. Assess the client’s vital signs.
- C. Have the unlicensed assistive personnel (UAP) stay with the client.
- D. Check the client’s telemetry reading.
Correct Answer: A
Rationale: Chest pain/anxiety in thromboembolism suggests pulmonary embolism; calling RRT (A) ensures rapid intervention. Vitals (B), UAP (C), and telemetry (D) follow.
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The nurse is discussing the importance of exercising with a client who is diagnosed with coronary artery disease. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis?
- A. Exercise promotes the development of collateral circulation.
- B. Isometric exercises help develop the client's muscle mass.
- C. Daily exercise helps prevent plaque from developing in the vessel.
- D. Isotonic exercises promote the transport of glucose into the cell.
Correct Answer: A
Rationale: Walking promotes collateral circulation (A), improving blood flow in CAD. Isometric exercises (B) increase BP, plaque prevention (C) is indirect, and glucose transport (D) is unrelated.
Which finding should the nurse report immediately in a client with a deep vein thrombosis (DVT)?
- A. Warm, red skin over the affected area
- B. Mild leg pain
- C. Heart rate of 80 beats per minute
- D. Blood pressure of 130/85 mmHg
Correct Answer: A
Rationale: Warm, red skin over the affected area may indicate worsening DVT or complications like thrombophlebitis, requiring immediate attention.
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
- A. The client has spontaneous bleeding from around the IV site.
- B. The client complains of chest pain on inspiration and has become restless.
- C. The client’s platelet count on admission was 420 (103) and now is 200 (103).
- D. The client complains that the gums bleed when brushing the teeth.
- E. The client has developed skin lesions at the IV site.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (A), platelet drop from 420 to 200 (C), and gum bleeding (D) are signs. Chest pain/restlessness (B) suggests PE, and skin lesions (E) are not typical.
The client prescribed rivaroxaban (Xarelto), an anticoagulant, is complaining of dark, tarry stool. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Ask the client to provide a stool sample.
- C. Ask the client when the rivaroxaban was last taken.
- D. Assess the client for ecchymotic areas and bleeding.
Correct Answer: A
Rationale: Dark, tarry stool suggests GI bleeding; notifying HCP (A) is first for urgent evaluation. Stool sample (B), last dose (C), and bleeding assessment (D) follow.
The client diagnosed with a deep vein thrombosis is prescribed heparin via continuous infusion. The client's laboratory data are: PT 12.2 aPTT 48 Control 1.4 Control 32 INR 1 Based on the laboratory results, which intervention should the nurse implement?
- A. Request a change of medication to a subcutaneous anticoagulant.
- B. Administer AquaMephyton (vitamin K) IM.
- C. Have the dietary department remove all green, leafy vegetables from the trays.
- D. Administer the IV as ordered.
Correct Answer: D
Rationale: aPTT 48 (therapeutic 1.5–2× control 32 = 48–64) is within range; continue heparin as ordered (D). Subcutaneous (A) is inappropriate, vitamin K (B) reverses heparin, and diet (C) is for warfarin.