A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

Partial thromboplastin time (PTT) 65 seconds

Hematocrit 45%

White blood cell count 8.000/mm3

Platelets

Answer and Explanation

The Correct Answer is A

A. Partial thromboplastin time (PTT) 65 seconds: The normal PTT range is typically between 25 to 35 seconds for patients not on anticoagulants. For a patient receiving heparin therapy, the therapeutic PTT range is usually 1.5 to 2.5 times the normal value, which translates to approximately 60 to 100 seconds. A PTT of 65 seconds is at the lower end of the therapeutic range and may require adjustment in dosage or closer monitoring, especially if there are concerns about achieving adequate anticoagulation for the treatment of a pulmonary embolism. It is important to report this value to the provider.

B. Hematocrit 45%: A hematocrit of 45% is within the normal range for adult females (38% to 47%) and males (40% to 54%). This value does not indicate any immediate concern related to heparin therapy or the treatment of a pulmonary embolism.

C. White blood cell count 8.000/mm³: A white blood cell count of 8,000/mm³ is within the normal range (4,500 to 11,000/mm³) and does not indicate any infection or inflammatory process that requires immediate reporting.

D. Platelets: The specific platelet count value is not provided. However, heparin therapy can lead to thrombocytopenia (low platelet count), so if the platelet count is below 150,000/mm³, it should be reported to the provider. Without the specific value, it is not possible to determine if this requires reporting.

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Correct Answer is A

Explanation

A. 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. The Braden Scale scores range from 6 to 23, with lower scores indicating higher risk. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment, making this the best sign that the risk for skin breakdown has been removed.

B. 13: A score of 13 indicates moderate risk for skin breakdown. While this is an improvement from a score of 15, it still shows that the patient remains at risk and requires ongoing monitoring and intervention.

C. 23: A score of 23 indicates very low risk for skin breakdown; however, it is not a feasible score for patients who were initially assessed at 15. Achieving this score would likely suggest an unrealistic improvement in the patient's condition based solely on nursing interventions.

D. 12: A score of 12 indicates a high risk for skin breakdown. This score signifies that the risk has not been effectively addressed, and the patient continues to be vulnerable to skin impairment.

A. Turn and reposition the patient every 2 hours. B. Apply hydrocolloid dressing to the pressure injury. C. Change pressure injury dressings every shift. D. Assess the patient's skin condition.

Correct Answer is A

Explanation

A. Turn and reposition the patient every 2 hours: This task can be delegated to nursing assistive personnel (NAP). NAPs are trained to assist with basic patient care tasks, including turning and repositioning patients to prevent pressure injuries and promote comfort.

B. Apply hydrocolloid dressing to the pressure injury: This task should not be delegated to NAPs, as applying dressings requires knowledge of wound care principles and techniques, which falls under the scope of nursing practice.

C. Change pressure injury dressings every shift: Changing dressings is a nursing responsibility that requires assessment and skill in managing wound care. This task should be performed by the nurse to ensure proper technique and evaluate the wound condition.

D. Assess the patient's skin condition: Skin assessment is a nursing responsibility that requires clinical judgment and expertise. The nurse must assess the skin to identify any changes or complications related to pressure injuries, which should not be delegated to NAPs.

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A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Correct Answer is A

Explanation

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is A

Explanation

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