heparin question

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Just had this on an exam...

After giving a sub q heparin injection, which would require the nurse to contact the MD...

a. a bp of 90/48

b. abdominal bruising

Just wondering cause the rational that we were giving was a bit confusing.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

after giving a sub q heparin injection, which would require the nurse to contact the md...

a. a bp of 90/48

b. abdominal bruising

i would answer "a". abdominal bruising is usually expected side effect with heparin. a diastolic b/p of 48 indicates trouble. this patient could already be suffering a blood loss which is why their b/p is so low. normal b/p for an adult is 100-139/60-89. that goes back to basic fundamentals of nursing. did they trip you up on that? you have to always be thinking.

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