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. Hypocalcemia is correct because esomeprazole, a proton pump inhibitor, can lead to decreased calcium absorption, resulting in low calcium levels, which can cause muscle cramps.
B. Hyperkalemia is incorrect; while potassium levels can be affected by various medications, muscle cramps are not typically associated with high potassium levels.
C. Hypercalcemia is incorrect as it refers to elevated calcium levels, which would not cause muscle cramps and could actually lead to muscle weakness rather than cramping.
D. Hyponatremia is incorrect; low sodium levels may cause other symptoms but are not specifically linked to muscle cramps in the same way as low calcium levels are.
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.