A client is receiving heparin sodium by continuous intravenous (IV) infusion. The nurse should notify the health care provider if ongoing nursing assessment reveals which finding?
1. Tinnitus
2. Ecchymosis
3. Increased pulse rate
4 Increased blood pressure
Answer: 2. Ecchymosis
Explanation: The client who receives a continuous IV infusion of heparin sodium is at risk for bleeding. The nurse assesses for signs/symptoms of bleeding, which include bleeding from the gums, ecchymosis on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The other options are not side or adverse effects related to this medication.
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A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter.
When caring for a client experiencing breakthrough nausea and vomiting related to chemotherapy, assuming prescriptions are available if needed, the nurse should:
a. administer promethazine IM. b. explain to the client that the nausea will decrease soon. c. encourage the client to drink ginger ale. d. administer lorazepam IV.
The nurse is preparing to provide a dose of liquid oral antibiotic to a 2-year-old whose mother reports, "She doesn't like the taste of that and won't take it without a fight."
To successfully provide the medication, the nurse could appropriately do which of the following? Select all that apply. 1. Offer the child a warm bottle with the medication mixed in. 2. Offer the child a frozen juice bar before medication administration. 3. Discuss the addition of a flavoring with the pharmacist. 4. Place a syringe at the tip of the child's tongue and encourage the child to suck out the medication. 5. Place the dose in a plastic medicine cup and encourage the child to "drink it like a big girl."
A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate:
1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight.