HESI RN Exit Proctored Exam
Select All That Apply
A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.
Explanation & Rationale
A. Warfarin is not administered in this situation unless directed by a provider; the priority is addressing possible bleeding. B. Reviewing the last PTT results is important to assess the effectiveness of heparin and monitor for potential bleeding complications. C. Assessing the characteristics of pain can help determine if the client is experiencing gastrointestinal bleeding, which is a concern with heparin therapy. D. Monitoring for blood in the stool is crucial, as tarry stools indicate possible gastrointestinal bleeding, a known complication of anticoagulation therapy. E. Auscultating bowel sounds is important but does not directly address the potential complication of gastrointestinal bleeding, which is the priority in this situation.
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