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. While assessing potassium levels is important for clients on diuretics, the immediate concern is the client's dizziness, which indicates a potential issue with blood pressure.
B. Teaching the client about the potential for orthostatic hypotension caused by hydrochlorothiazide and instructing them on safety measures (e.g., standing up slowly) is crucial to prevent falls and address the dizziness.
C. Bed rest is not necessary; the client should be educated about managing dizziness instead.
D. Withholding the medication is not warranted unless directed by a healthcare provider; the focus should be on safety education.
Correct Answer is A
Explanation
A. Reye syndrome is correct because administering aspirin to children, especially during viral illnesses like the flu, can lead to this serious and potentially fatal condition characterized by acute encephalopathy and liver failure.
B. Excess antiplatelet action is incorrect; while aspirin does have antiplatelet effects, this is not the primary concern in a child with a viral illness.
C. Asthma is incorrect; while some individuals with asthma may have sensitivity to aspirin, it is not specifically related to the child's flulike illness.
D. Salicylate poisoning is incorrect; while high doses of aspirin can lead to toxicity, the immediate risk in the context of flu-like illness is Reye syndrome, which is a more specific concern.