A nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. Which of the following findings should the nurse identify as a possible indication of hemorrhage?

Correct Answer: A

Rationale: The correct answer is A: Rapid pulse. Hemorrhage is a potential complication of anticoagulant therapy with heparin due to the increased risk of bleeding. A rapid pulse can indicate hypovolemia from blood loss, a common sign of hemorrhage. Yellowing of the sclera (choice B) is a sign of jaundice, not directly related to hemorrhage. Elevated blood pressure (choice C) is not typically associated with hemorrhage. Pale-colored stools (choice D) can be indicative of liver or gallbladder issues, but not specifically hemorrhage. Overall, a rapid pulse is the most relevant finding to indicate possible hemorrhage in a client on heparin therapy.

Correct Answer: A

Rationale: The correct answer is A: Pancytopenia. Aplastic anemia is characterized by a decrease in all blood cell types (red blood cells, white blood cells, and platelets), leading to pancytopenia. This is due to bone marrow failure, resulting in decreased production of blood cells. Erythrocytosis (B) is an increase in red blood cells, which is the opposite of what is seen in aplastic anemia. Bone marrow hypercellularity (C) is not typically observed in aplastic anemia, as the bone marrow is usually hypocellular. Reticulocytosis (D) is an increase in immature red blood cells and is not a characteristic finding in aplastic anemia where there is decreased production of all blood cell types.

Correct Answer: A

Rationale: The correct term to describe hemoglobin that has given up its oxygen to the body's cells is "Reduced" (Choice A). This term refers to hemoglobin that has released its oxygen molecules and is now in a deoxygenated state. Rationale: 1. Hemoglobin binds to oxygen in the lungs (forming oxyhemoglobin). 2. When hemoglobin reaches the body's cells, it releases oxygen for cellular use. 3. Once hemoglobin releases oxygen, it becomes deoxygenated or "Reduced". Summary: - Choice B (Detached) does not accurately describe the process of oxygen release by hemoglobin. - Choice C (Oxyhemoglobin) refers to hemoglobin bound to oxygen, not hemoglobin that has released oxygen. - Choice D (Hypoxyhemoglobin) would refer to hemoglobin that has a reduced oxygen level, not hemoglobin that has given up its oxygen to the cells.

Correct Answer: C

Rationale: The correct answer is C: Clubbed fingertips. Clubbing is a sign of prolonged hypoxia due to chronic lung disease. It is characterized by enlargement and rounding of the fingertips. This occurs as a result of chronic hypoxia causing tissue changes in the fingers. Pallor (A) is a pale skin color often indicating decreased blood flow. Dyspnea (B) is difficulty breathing and can be an acute symptom of hypoxia. Pulmonary crackles (D) are abnormal lung sounds indicating fluid accumulation and are not specific to long-term hypoxia.

Correct Answer: C

Rationale: The correct first action is to discontinue the blood transfusion (Choice C). This is because the patient's symptoms of severe chest pain and warmth suggest a possible transfusion reaction, which can be life-threatening. By stopping the transfusion, the nurse can prevent further harm to the patient. Calling the physician (Choice A) can be done after stopping the transfusion. Administering diuretics (Choice B) without knowing the cause of symptoms can exacerbate the situation. Assessing vital signs and cardiovascular status (Choice D) is important but should come after stopping the transfusion to prioritize patient safety.