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. Confirming that the medication prescribed is the drug of choice for the specific microorganism is crucial in ensuring effective treatment, as the right drug will target the identified infection.
B. Teaching the client that significant adverse effects are expected and must be endured is not a supportive approach; the focus should be on managing and minimizing adverse effects rather than accepting them.
C. Administering antihistamines may not be relevant for all patients undergoing anti-infective treatment and is not a primary strategy for ensuring treatment success.
D. Monitoring for signs of arrhythmias or cardiac ischemia is not directly related to ensuring the success of anti-infective treatment; it may be necessary for certain medications but does not address the effectiveness of anti-infectives specifically.
Correct Answer is ["B","C","D"]
Explanation
A. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.