A patient is receiving heparin postoperatively to prevent deep vein thrombosis. The nurse notes that the patient has a blood pressure of 90/50 mm Hg and a heart rate of 98 beats per minute
The patient's most recent aPTT is greater than 90 seconds. The patient reports lumbar pain. The nurse will request an order for:
a. a repeat aPTT to be drawn immediately.
b. analgesic medication.
c. changing heparin to aspirin.
d. protamine sulfate.
ANS: D
Heparin overdose may cause hemorrhage, which can be characterized by low blood pressure, tachycardia, and lumbar pain. Protamine sulfate should be given, and the heparin should be discontinued. An aPTT may be drawn later to monitor the effectiveness of protamine sulfate. Analgesics are not indicated because the lumbar pain is likely caused by adrenal hemorrhage. Aspirin will only increase the risk of hemorrhage.
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Eczema indicates that the infant is oversensitive to certain substances called ______________, which enter the body via the digestive tract, inhalation, direct contact, or injections
ANS:
A nurse aims to provide social support for a family to influence which of the following family outcomes?
1. Improved family health 2. Increased powerlessness in family members 3. Increased anxiety and depression in family member 4. Decreased problem solving in family members
The nurse manager is planning a presentation on ethical issues in caring for childbearing families. Which example should the nurse manager include to illustrate maternal-fetal conflict?
1. A client chooses an abortion after her fetus is diagnosed with a genetic anomaly. 2. A 39-year-old nulliparous client undergoes therapeutic insemination. 3. A family of a child with leukemia requests cord-blood banking at this birth. 4. A cesarean delivery of a breech fetus is court ordered after the client refuses.
The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure?
1. The condition of the skin and nails 2. Nothing unless a problem is noted 3. The amount of time taken on foot care 4. The client's comments about the foot care