Question

a nurse is monitoring a client who is undergoing anticoagulant therapy with heparin. which of the following findings should the nurse identify as a possible indication of hemorrhage?

• rapid pulse
• yellowing of the sclera
• elevated blood pressure
• pale - colored stools

Explanation:

To determine the correct answer, we analyze each option:

• Rapid pulse: Hemorrhage leads to decreased blood volume, triggering the body to increase heart rate to maintain perfusion, so this is a sign of possible hemorrhage.
• Yellowing of the sclera: Indicates jaundice (liver issues, bilirubin elevation), not related to hemorrhage from heparin therapy.
• Elevated blood pressure: Hemorrhage causes hypovolemia, leading to decreased blood pressure, not elevated.
• Pale - colored stools: Associated with biliary obstruction (blocked bile flow), not hemorrhage.

Answer:

A. Rapid pulse