As the nurse is completing the physical assessment of a client receiving heparin therapy for deep vein thrombosis (DVT), the client complains of severe lumbar pain. Which is the nurse's priority action?
1. Evaluate further because this could indicate a complication of drug therapy.
2. Reposition the client to promote comfort.
3. Administer pain medication.
4. Document the finding and report it to the next shift.
Correct Answer: 1
Rationale 1: A major side effect of heparin is bleeding. Lumbar pain and unilateral abdominal wall bulges or swelling could indicate retroperitoneal hemorrhage.
Rationale 2: Only providing comfort measures is not appropriate.
Rationale 3: Administering pain medication might be appropriate, but it is not the priority action.
Rationale 4: Documenting and reporting the pain to the next shift could allow any adverse effects to worsen.
Global Rationale: A major side effect of heparin is bleeding. Lumbar pain and unilateral abdominal wall bulges or swelling could indicate retroperitoneal hemorrhage. Only providing comfort measures is not appropriate. Administering pain medication might be appropriate, but it is not the priority action. Documenting and reporting the pain to the next shift could allow any adverse effects to worsen.
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