DEEP VEIN THROMBOSIS HESI CASE
STUDY FINAL EXAM WITH
COMPREHENSIVE ANSWERS.
Based on the nurse's assessment which cues support the decision to provide
intervention for the client's pain as the first priority? (Select all that apply.
One, some, or all options may be correct.) - CorreCt Answers -Blood
pressure.
Client's reported pain level of 7/10.
History of rheumatoid arthritis.
Recent hip surgery within the last 3 months.
Examination of the client's right lower extremity.
Heparin overdose can cause life threatening hemorrhaging, such as
nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising.
Which of these actions should the nurse take for the client's safety? (Select
all that apply. One, some, or all options may be correct.) - CorreCt Answers
-Stop the heparin infusion.
Obtain a stat APTT.
Assess vital signs.
, Anticipate a prescription of protamine sulfate.
After consulting with the HCP, the nurse is to administer a heparin
antagonist. The nurse explains to the client that protamine sulfate is being
administered to obtain which expected outcome? - CorreCt Answers -
Reduce hematuria.
Another less common complication of heparin therapy is Heparin Induced
Thrombocytopenia (HIT). What if the client develops fever and chills?
Based on these cues, the nurse recognizes that it is essential to obtain which
information first? - CorreCt Answers -Platelet count.
What information is included in an Incident Report? (Select all that apply.
One, some, or all options may be correct.) - CorreCt Answers -Person who
witnessed event writes report.
Injuries resulting from incident.
Response and corrective measures taken
Review the incident involving the client's IV pump and hematuria. What
specific information resulting from this event should be included in the
client's incident report? (Select all that apply. One, some, or all options may
be correct.) - CorreCt Answers -Day nurse received prescription to decrease
Heparin infusion to 30 mL/hour.
Nurse took action and stopped infusion.
STUDY FINAL EXAM WITH
COMPREHENSIVE ANSWERS.
Based on the nurse's assessment which cues support the decision to provide
intervention for the client's pain as the first priority? (Select all that apply.
One, some, or all options may be correct.) - CorreCt Answers -Blood
pressure.
Client's reported pain level of 7/10.
History of rheumatoid arthritis.
Recent hip surgery within the last 3 months.
Examination of the client's right lower extremity.
Heparin overdose can cause life threatening hemorrhaging, such as
nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising.
Which of these actions should the nurse take for the client's safety? (Select
all that apply. One, some, or all options may be correct.) - CorreCt Answers
-Stop the heparin infusion.
Obtain a stat APTT.
Assess vital signs.
, Anticipate a prescription of protamine sulfate.
After consulting with the HCP, the nurse is to administer a heparin
antagonist. The nurse explains to the client that protamine sulfate is being
administered to obtain which expected outcome? - CorreCt Answers -
Reduce hematuria.
Another less common complication of heparin therapy is Heparin Induced
Thrombocytopenia (HIT). What if the client develops fever and chills?
Based on these cues, the nurse recognizes that it is essential to obtain which
information first? - CorreCt Answers -Platelet count.
What information is included in an Incident Report? (Select all that apply.
One, some, or all options may be correct.) - CorreCt Answers -Person who
witnessed event writes report.
Injuries resulting from incident.
Response and corrective measures taken
Review the incident involving the client's IV pump and hematuria. What
specific information resulting from this event should be included in the
client's incident report? (Select all that apply. One, some, or all options may
be correct.) - CorreCt Answers -Day nurse received prescription to decrease
Heparin infusion to 30 mL/hour.
Nurse took action and stopped infusion.
