A patient receiving heparin therapy develops bruising and bleeding gums. What should the nurse suspect and what is the appropriate action?
Suspect an allergic reaction and administer antihistamines.
Suspect a bleeding complication and notify the healthcare provider.
Suspect a hypersensitivity reaction and discontinue the heparin immediately.
Suspect an infection and initiate antibiotic therapy.
The Correct Answer is B
A. Bruising and bleeding gums are not indicative of an allergic reaction, which would typically present with different symptoms such as rash, itching, or swelling. Administering antihistamines would not address the underlying issue.
B. The development of bruising and bleeding gums in a patient on heparin therapy suggests a bleeding complication, which is a known risk of anticoagulation therapy. The nurse should notify the healthcare provider to assess the situation and possibly adjust treatment or perform further evaluations.
C. While hypersensitivity reactions can occur with medications, the symptoms presented here are more aligned with bleeding complications than with hypersensitivity. Discontinuing heparin without consulting the provider could put the patient at risk for thromboembolic events.
D. The symptoms do not indicate an infection; therefore, initiating antibiotic therapy would not be appropriate in this context.
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Correct Answer is A
Explanation
A. Blood pressure is correct because both nitroglycerin and diltiazem can cause vasodilation, leading to hypotension; thus, monitoring blood pressure is crucial for patient safety.
B. Level of consciousness is incorrect; while important, it is not the primary concern in this context.
C. Daily weights are incorrect; they are more relevant for assessing fluid status over time, not immediate drug effects.
D. Respiratory status is incorrect; while monitoring is important, blood pressure takes precedence due to the risk of hypotension associated with these medications.
Correct Answer is C
Explanation
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B. Warm, dry skin is not a direct indicator of the effectiveness of isoproterenol; it could result from various factors unrelated to the medication's action.
C. Increased heart rate indicates that isoproterenol, which is a beta-agonist, is effectively stimulating the beta-adrenergic receptors, leading to increased cardiac output and heart rate.
D. Decreased urine output is not a sign of effectiveness and could indicate adverse effects such as reduced renal perfusion.