A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the following is an expected finding?

A. Turn off the heparin drip: The client’s aPTT is significantly elevated and is accompanied by active bleeding, indicated by hematuria. Stopping the heparin infusion is the most immediate action because it removes the source of ongoing anticoagulation and helps prevent further bleeding. This stabilizes the situation before additional corrective measures are taken.

B. Administer protamine sulfate: Protamine sulfate is the reversal agent for heparin and may be required, but it should be given after the heparin infusion is stopped. Administering it without stopping the drip allows continued anticoagulation, reducing the effectiveness of the reversal. The reversal medication is a secondary intervention.

C. Repeat the aPTT now and in 1 hr: Rechecking coagulation labs is appropriate to monitor progress, but it does not address the immediate risk of ongoing bleeding. Delaying action while repeating labs can allow further anticoagulation and worsening hemorrhagic symptoms. Lab monitoring becomes relevant only after the heparin drip is stopped.

D. Obtain a portable chest x-ray: A chest x-ray would not address the current problem of excessive anticoagulation and active bleeding. There is no indication of a thoracic complication requiring imaging at this moment, and performing this step would delay urgent action. The priority is to stop the heparin and control bleeding.

A. An air leak noted at the insertion site: An air leak can cause continuous bubbling in the water seal chamber, but it does not prevent tidaling. Tidaling reflects intrathoracic pressure changes with respiration, so an air leak alone does not explain the absence of tidaling.

B. The tubing may be kinked: Tidaling stops when there is an obstruction in the chest tube system, such as a kinked or clamped tube. This prevents the normal movement of fluid in the water seal chamber that corresponds with the client’s respiratory cycle, making it the most likely cause of absent tidaling.

C. Water needs to be added to the suction-control chamber: Low water in the suction-control chamber affects the amount of suction delivered, not tidaling in the water seal chamber. The water seal chamber relies on the client’s respiration to show fluctuations, so adding water to suction does not restore tidaling.

D. The suction is set too low: Suction settings influence the rate of fluid evacuation and bubbling, but they do not control tidaling. Absence of tidaling usually indicates a mechanical obstruction rather than a suction problem.