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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is assigned to care for a client who is receiving a continuous intravenous (IV) heparin infusion to treat a deep vein thrombosis (DVT). Which of the following actions should the PN take to reduce the risk of potential complications? Select all that apply.

  1. Institute bleeding precautions by providing a soft-bristle toothbrush and an electric razor.Cevap
  2. Monitor the client's urine and stool output for the presence of occult or frank blood.Cevap
  3. C
    Prepare to independently administer intravenous (IV) push protamine sulfate in the event of severe hemorrhage.
  4. Evaluate the client promptly for any sudden onset of chest pain, tachycardia, and dyspnea.Cevap
  5. E
    Withhold the heparin infusion and notify the provider if the morning platelet count is 240,000/mm3240,000/\text{mm}^3.
  6. F
    Document a blood pressure of 92/58 mm Hg with a heart rate of 112 beats per minute as expected baseline findings.

Cevap

The practical nurse should institute bleeding precautions, monitor output for the presence of blood, and evaluate the client promptly for sudden chest pain, tachycardia, and dyspnea.
To reduce risk potential, the PN must prioritize interventions that address the most significant threats to the client: bleeding (due to heparin) and pulmonary embolism (due to the DVT). Implementing bleeding precautions (electric razor, soft toothbrush) and monitoring excreta for occult blood directly mitigate and detect hemorrhage. Assessing for sudden chest pain and shortness of breath ensures rapid detection of a pulmonary embolism, which is a medical emergency.

Adım Adım Çözüm

1
Identify the primary clinical risks associated with the client's diagnosis and prescribed treatment.
The client is at high risk for hemorrhage due to the continuous heparin infusion and at risk for a pulmonary embolism (PE) due to the presence of a deep vein thrombosis.
Recognizing specific risk factors guides the nurse in selecting appropriate targeted assessments and preventive interventions.
2
Evaluate each nursing action against the identified risks and the established LPN/LVN scope of practice.
Providing an electric razor, monitoring stool/urine for blood, and assessing for signs of a PE are appropriate risk reduction strategies within the PN scope.
These actions directly mitigate the risk of bleeding and ensure early detection of life-threatening complications.
3
Identify and eliminate actions that are unsafe, outside the scope of practice, or represent clinical misinterpretations.
Administering IV push medications, withholding therapy for a normal platelet count, and dismissing early signs of shock are incorrect and unsafe actions.
Adhering to scope of practice and accurately interpreting objective clinical data are essential components of safe client care.

Anahtar Kavram

Reduction of Risk Potential: Anticoagulant Therapy Monitoring and Complication Recognition
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Reduction of Risk Potential

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