AS a home health nurse, you are obtaining an admission history for a client with a deep vein thrombosis and is taking warfarin (Coumadin) 2mg daily. Which statement by the client indicates the need for additional medication teaching?

What action will the nurse take when administering Heparin subcutaneously?

Case Summary A 69-year-old male client is admitted to the medical-surgical unit for an evaluation of pain and edema of the right lower extremity. The onset of symptoms was 2 days prior to arrival. Client is diagnosed with a deep vein thrombosis requiring heparin therapy. The nurse on the medical-surgical unit is caring for a 69-year-old male client with pain and swelling of the right lower extremity.   Nurses’ Notes     Day 1. 0930 Admission note: Client admitted from the Emergency Department via stretcher and transferred to bed. Client is alert and oriented. Saline lock IV in the R antecubital vein patent. Right lower extremity noted to have 2+ pedal edema, pain 8/10 in right calf. Warmth noted to right calf. Client has positive motion and sensation to right lower extremity. Right pedal pulse weak, palpable. R lower extremity elevated on 2 pillows.  VS: BP 145/82, HR 96, RR 16, Temp 36.7C (98F). Client ordered to be on complete bedrest. Client made aware 1010: Radiology called results of right leg ultrasound: positive for deep vein thrombosis of the right posterior tibial vein. Provider made aware. New orders pending. 1018: Orders have been entered. Orders   Category Orders Labs: Draw Prothrombin Time (Pt), Partial Thromboplastin Time (PTT) STAT Medications: Administer Heparin 80 units/Kg IV bolus now. After initial bolus begin Heparin Weight-Based Protocol Continuous IV Infusion: Starting dose: 18 units/Kg/hr. Draw serum PTT 6 hours after infusion begins, then Q 6 hours. Call results Nursing: Activity: strict bedrest Place compression stockings on bilateral lower extremities Elevate to right lower extremity Closely monitor for signs of bleeding  The nurse reviews the physician’s orders. Based upon the new information given, what is a priority action by the nurse within the hour of the administration of Heparin 80 units/kg/hr?

What is the primary collaborative goal of a client with lymphedema and resultant fluid volume excess?

A client is admitted with neutropenia. What is the nurse’s priority intervention?

Which information, shown in the Chart below, about a client who just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?

Which intervention will be most effective in preventing thrombophlebitis in the post-operative client?

The nurse instructs a client about foods rich in iron. Which of the following foods will be included in the diet?

A client with renal failure has decreased erythropoietin production. Upon analysis of the client’s complete blood count, the nurse will expect which of the following complete blood count results?

You have assessed a comatose client that is having periods of hyperventilation that gradually diminish to apnea, then resume, gradually building to hyperventilation.  What documentation is most appropriate regarding the client’s breathing pattern?