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    HESI RN Exit VI Proctored Exam
    Select All That Apply

    A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin 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. Auscultating bowel sounds in all quadrants helps assess the extent of gastrointestinal involvement and possible complications.B. Administering warfarin is not appropriate in this acute situation where there may be active bleeding; instead, the heparin infusion should be stopped.C. Assessing the characteristics of the pain is crucial for determining the severity and possible source of the gastrointestinal symptoms.D. Monitoring stools for the presence of blood is essential to confirm gastrointestinal bleeding and the extent of blood loss.E. Reviewing the last partial thromboplastin time results helps assess the anticoagulation status of the client and the potential need for reversal.

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