Deep Vein Thrombosis HESI question and answer Based on the nurse's assessment which cues support the decision to provide intervention for the client's pain as the first priority? (Select all that apply. One, some, or all options may be correct.) - answer Blood pressure.Client's reported pain level of 7/10.History of rheumatoid arthritis.Recent hip surgery within the last 3 months.Examination of the client's right lower extremity.The client is describing the pain in her right leg as severe and concentrated in her foot and ankle. The nurse receives a prescription from the HCP for hydrocodone bitartrate and acetaminophen 5/325 two tabs PO prior to the client's exam. Before initiating the treatment, it is most important for the nurse to implement which interventions? (Select all that apply. One, some, or all options may be correct.) - answer Perform a focused assessment on the lower right extremity.Implement a numeric pain assessment on a scale of 1 to 10.Document a baseline of vital signs including a pulse oximetry.Use at least two client identifiers before administering the medication.Which non-pharmacologic nursing interventions will reduce pain related to decreased venous flow? (Select all that apply. One, some, or all options may be correct.) - answer Elevate the affected leg.Apply a warm compress.The nurse must educate the client about the venous ultrasound by distinguishing it from the venography. Which description accurately expresses these diagnostic tests? - answer If doppler studies are negative and a DVT is still suspected, a venogram may be needed to make accurate diagonis.Anticoagulants are the drug of choice for clients with actual DVT and so the HCP prescribed Heparin therapy for the client. Which conclusions regarding Heparin administration are accurate? (Select all that apply. One, some, or all options may be correct.) - answer Heparin infusion requires laboratory monitoring and dose adjustment. 1 / 2
Heparin is known to cause medical complications even death.Heparin therapy is administered via intravenous route.Protamine sulfate is the anecdote for heparin.When the heparin therapy is initiated, the nurse analyzes which lab value to determine that a therapeutic heparin level has been reached? - answer APTT 65 seconds, control 35 seconds.What is the correct IV bolus dose of heparin the nurse should administer? (Enter numerical value only. If rounding is necessary, round to the tenth.) mL ______ Submit - answer 6 Refer to the HCP prescription and calculate the continuous infusion rate for the IV dosage of heparin. _____ units/hr. - answer 1650 The nurse completes preparation of the initial heparin infusion and prior to administering takes which of the following actions? (Select all that apply. One, some, or all options may be correct.) - answer Assesses client for allergies.Identifies client with two forms of identification.Ensure the client's IV access is intact and patent.Verifies baseline coagulation studies have been drawn.Initiates two nurses to check calculation accuracy.At what rate should the IV pump be set to deliver the prescribed rate of infusion? (Enter numerical value only. If rounding is necessary, round to the whole number.) _____ mL/hr - answer 33 During heparin therapy, the client's APTT is monitored every 6 hours and the midnight results were APTT 120 seconds, control 35 seconds.Based on these cues, what action should the nurse expect to initiate? - answer Decrease and maintain this rate until the next APTT check in 6 hours.The incoming nurse notices which cue as the cause of observable hematuria in the client's urinary catheter? - answer The IV pump infusing at a higher rate than prescribed.Heparin overdose can cause life threatening hemorrhaging, such as nosebleeds, coffee grounds emesis, blood in urine and stools, and bruising. Which of these actions should
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