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","B","D","E"]
Explanation
A. Administering drugs is a fundamental duty of the nurse, ensuring that medications are given safely and according to protocols.
B. Monitoring clients for drug effects is crucial for assessing the effectiveness of medications and identifying any adverse reactions or complications.
C. Prescribing drugs is not a duty performed by nurses, as this responsibility typically falls under the purview of licensed practitioners such as physicians or nurse practitioners.
D. Evaluating clients for toxic effects is part of the nurse's responsibility to ensure patient safety and to respond to any signs of medication toxicity.
E. Educating clients/caregivers about drugs is a vital role for nurses, as it helps patients understand their medications and the importance of adherence to prescribed regimens.
Correct Answer is D
Explanation
A. While MAOIs may have some regulatory considerations, they are not classified under a scheduled drug classification like controlled substances.
B. MAOIs are effective in treating depression and anxiety disorders, which is not the reason for their limited use.
C. Although MAOIs can have some side effects, they are more notably associated with dietary and drug interactions rather than causing GI bleeding or esophageal varices.
D. MAOIs can cause dangerous interactions with foods that contain tyramine (like aged cheeses and fermented products) and certain medications, leading to hypertensive crises, making their use cautious and limiting in clinical practice.