A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

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Question 1 of 4

A nurse is reviewing the medical record of a client who is receiving heparin to treat deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: A platelet count of 80,000/mm3 is below the normal range and should be reported to the provider due to the risk of bleeding. Heparin can cause a rare but serious side effect known as heparin-induced thrombocytopenia, leading to a decrease in platelet count and an increased risk of bleeding. The aPTT of 38 seconds, hemoglobin of 15 g/dL, and an INR of 1.0 are within normal ranges and not directly concerning in this scenario. Platelet count is crucial to monitor in clients receiving heparin therapy to ensure adequate clotting function and prevent bleeding complications.

Question 2 of 4

A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.

Question 3 of 4

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

Correct Answer: D

Rationale: The correct answer is D: 'Monitor for signs of infection.' Clopidogrel affects platelet levels, increasing the risk of bleeding. Therefore, it is essential for clients taking clopidogrel to monitor for signs of infection, which could indicate a lowered immune response. Choices A, B, and C are incorrect because they do not directly relate to the specific monitoring needs associated with clopidogrel therapy.

Question 4 of 4

A nurse is teaching a client who has a new prescription for alendronate. Which of the following client statements indicates an understanding of the teaching?

Correct Answer: B

Rationale: The correct answer is B. Alendronate should be taken with a full glass of water before breakfast to prevent esophageal irritation and improve absorption. Choice A is incorrect as alendronate is not associated with causing drowsiness. Choice C is incorrect because alendronate can be taken with or without food, so avoiding dairy products is not necessary. Choice D is incorrect as the recommended time to remain upright after taking alendronate is 30 minutes to 1 hour, not just 30 minutes.

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