A pt in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vs, the pt has blood on the front of his chest and nose and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take?
a. have the pt sit up and lean forward, pinching the nostrils
b. have a pt care technician set up oral suctioning to suction excess blood from pts mouth
c. stop the heparin IV infusion
d. obtain lab results for prothrombin time and CBC
Answer: c. stop the heparin IV infusion
You might also like to view...
Sirolimus is used to prevent renal transplant rejection in an adult patient. Why is the patient at risk for the development of myocardial infarction?
A) An adverse effect of the medication is thrombocytopenia. B) An adverse effect of the medication is nephrotoxicity. C) An adverse effect of the medication is hypercholesterolemia. D) An adverse effect of the medication is leukopenia.
What is the foundational difference between the typical LPN/LVN and RN curriculums?
A) While the conceptual models are similar, interpretation of principles differ B) LPN/LVN curriculum has a focus on the client's medical condition C) RN curriculums stress the interdependence between medicine and nursing D) Skills mastery is viewed differently in the various programs
A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. The nurse should:
a. review the directive with the patient to ensure it is current. b. ensure that the directive is respected in treatment planning. c. consider the directive only if there is a cardiac or respiratory arrest. d. encourage the patient to revise the directive in light of the current health problem.
Which is the term for a family in which the paternal grandmother, the parents, and two minor children live together?
a. Blended b. Nuclear c. Binuclear d. Extended