Author Question: As the nurse is completing the physical assessment of a client receiving heparin therapy for deep ... (Read 39 times)

evelyn o bentley · **on:** Jul 23, 2018

As the nurse is completing the physical assessment of a client receiving heparin therapy for deep vein thrombosis (DVT), the client complains of severe lumbar pain. Which is the nurse's priority action?

1. Evaluate further because this could indicate a complication of drug therapy.
2. Reposition the client to promote comfort.
3. Administer pain medication.
4. Document the finding and report it to the next shift.

Question 2

A hospitalized client is prescribed warfarin (Coumadin). The nurse teaches the client to avoid which food on the lunch selection menu?

1. Whole-wheat bread with margarine
2. Roast beef
3. Salt substitute
4. Broccoli salad

xMRAZ · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: A major side effect of heparin is bleeding. Lumbar pain and unilateral abdominal wall bulges or swelling could indicate retroperitoneal hemorrhage.
Rationale 2: Only providing comfort measures is not appropriate.
Rationale 3: Administering pain medication might be appropriate, but it is not the priority action.
Rationale 4: Documenting and reporting the pain to the next shift could allow any adverse effects to worsen.
Global Rationale: A major side effect of heparin is bleeding. Lumbar pain and unilateral abdominal wall bulges or swelling could indicate retroperitoneal hemorrhage. Only providing comfort measures is not appropriate. Administering pain medication might be appropriate, but it is not the priority action. Documenting and reporting the pain to the next shift could allow any adverse effects to worsen.

Answer to Question 2

Correct Answer: 4
Rationale 1: Whole-wheat bread with margarine is not high in vitamin K, and so is not contraindicated when a client receives warfarin (Coumadin).
Rationale 2: Roast beef is not high in vitamin K, and so is not contraindicated when a client receives warfarin (Coumadin).
Rationale 3: Salt substitute is not high in vitamin K, and so is not contraindicated when a client receives warfarin (Coumadin).
Rationale 4: Broccoli is high in vitamin K, and must be avoided when a client receives warfarin (Coumadin).
Global Rationale: Broccoli is high in vitamin K, and must be avoided when a client receives warfarin (Coumadin). Whole-wheat bread with margarine, roast beef, and salt substitute are not high in vitamin K, and so these foods are not contraindicated when a client receives warfarin (Coumadin).