Certified Medical-Surgical Registered Nurse Practice Exam

While caring for Mr. Palmer, what is essential for the nurse to monitor due to his heparin treatment?

1. Monitor his prothrombin time.

2. Observe him for signs of pulmonary embolism.

3. Limit his intake of foods high in vitamin K.

4. Check the femoral puncture site at frequent intervals.

The correct answer is: Check the femoral puncture site at frequent intervals.

Monitoring the femoral puncture site at frequent intervals is essential due to Mr. Palmer's heparin treatment. Heparin is an anticoagulant medication commonly used to prevent and treat thromboembolic disorders. When patients are receiving such treatment, there is an increased risk of bleeding, especially if they have undergone a procedure that involves vascular access, such as a femoral puncture. By consistently checking the puncture site, the nurse can quickly identify any signs of bleeding, hematoma formation, or other complications, thereby ensuring patient safety. In contrast, while monitoring prothrombin time is crucial for patients on warfarin therapy, heparin therapy is typically evaluated using activated partial thromboplastin time (aPTT) instead. Observing for signs of pulmonary embolism is always important in patients who may be at risk, but it does not specifically relate to the immediate concerns associated with heparin administration. Finally, dietary restrictions regarding vitamin K are relevant for patients on warfarin, not heparin, as heparin does not have the same dietary interactions as vitamin K can affect the action of warfarin. Hence, the focus on the femoral puncture site reflects the acute monitoring needed in the context