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. Performing a blood sugar analysis is important, but the immediate symptoms indicate hypoglycemia, and rapid treatment is necessary before confirming blood sugar levels.
B. Having the client drink a glass of orange juice provides a quick source of glucose to counteract hypoglycemia, which is the most appropriate initial response to address the client's symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an appropriate intervention for severe hypoglycemia but is not the initial step for a client who can still take oral carbohydrates.
D. Administering insulin would worsen the client's condition by lowering blood sugar levels further, which is not indicated in this scenario.
Correct Answer is C
Explanation
A. This insulin does not peak like short-acting insulin; glargine provides a consistent release of insulin without a peak effect.
B. Long-acting insulin is not meant to be taken with meals, as it provides basal control and is typically taken once daily, not with each meal.
C. This statement is correct; glargine provides a steady level of insulin over 24 hours, helping to maintain consistent blood glucose levels throughout the day and night.
D. Long-acting insulin is usually administered once daily, so stating that it must be given three times a day is incorrect.