A nurse is caring for a client who has been taking warfarin and has a prothrombin time of 30 seconds and an INR of 7. Which of the following medications should the nurse anticipate the provider to prescribe?

A. Alteplase (Activase): Alteplase is a thrombolytic agent used to dissolve blood clots. Concurrent use with clopidogrel, an antiplatelet medication, can increase the risk of bleeding due to additive effects on clotting. Therefore, it's important to consult the doctor before using these medications together.

B. Diltiazem: Diltiazem is a calcium channel blocker used to treat hypertension and certain heart rhythm disorders. Diltiazem will decrease the level or effect of clopidogrel by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Therefore, it's advisable to consult the doctor before using these medications together.

C. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to relieve pain and inflammation. Like other NSAIDs, it can increase the risk of bleeding when taken with clopidogrel. Therefore, it's important to consult the doctor before using these medications together.

D. Aspirin: Aspirin is another antiplatelet medication commonly used to prevent heart attacks and strokes. Combining clopidogrel with aspirin can increase the risk of bleeding without significantly improving outcomes in most cases. However, in some situations, such as after certain cardiac procedures, dual antiplatelet therapy (clopidogrel plus aspirin) may be prescribed under close medical supervision. Therefore, it's crucial to consult the doctor before using these medications together.

E. Coumadin (warfarin): Coumadin is an anticoagulant medication used to prevent blood clots. Concurrent use with clopidogrel can increase the risk of bleeding. Therefore, it's essential to consult the doctor before using these medications together.

A. Platelets 74,000/mm: A platelet count of 74,000/mm³ is significantly lower than the normal range (typically 150,000 to 450,000/mm³). This could indicate heparin-induced thrombocytopenia (HIT), a serious adverse effect of heparin therapy where the immune system forms antibodies against heparin bound to platelet factor 4, leading to a decrease in platelets and increased risk of thrombosis. This is a critical finding and should be reported immediately to the provider for further evaluation and potential adjustment of the treatment plan.

B. White blood cell count 8,000/mm³: This is within the normal range (typically 4,000 to 11,000/mm³) and does not indicate an immediate problem related to heparin therapy or pulmonary embolism management.

C. Partial thromboplastin time (PTT) 55 seconds: While slightly elevated, this PTT is within the therapeutic range for a patient receiving IV heparin (typically 1.5 to 2.5 times the normal control value, or about 45 to 70 seconds). This indicates that the heparin is having the desired anticoagulant effect.

D. Hematocrit 45%: This is within the normal range for adults (typically 38-50% for men and 35-45% for women) and does not indicate an immediate concern related to heparin therapy or pulmonary embolism.