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 B
Explanation
A. Prothrombin time (PT) is used to monitor warfarin therapy, not heparin therapy.
B. Activated partial thromboplastin time (aPTT) is the primary laboratory test used to assess the effectiveness of heparin therapy, measuring the time it takes for blood to clot and ensuring therapeutic levels.
C. The International normalized ratio (INR) is also related to warfarin therapy rather than heparin.
D. Serum potassium level is not relevant for assessing heparin therapy but may be monitored for other reasons.
Correct Answer is B
Explanation
A. Performing a blood sugar analysis is important, but in the case of sudden symptoms such as weakness, shakiness, and dizziness, it is crucial to act quickly to address the potential hypoglycemia without delay.
B. Having the client drink a 4-ounce glass of orange juice is the most appropriate initial response as it provides a quick source of glucose to alleviate symptoms of hypoglycemia, which is a common concern in clients with type 1 diabetes experiencing these symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an effective treatment for hypoglycemia but is typically reserved for severe cases where the patient is unable to consume oral glucose or is unconscious.
D. Administering 10 units of regular insulin subcutaneously would exacerbate the problem by lowering blood sugar further and is contraindicated in a patient experiencing hypoglycemic symptoms.